Rental Buyout for Lost, Damaged or Totaled Assets

Original Order Number *

Asset Code Damaged, Lost or Stolen  *

Replacement Value for Asset

-- Please Select --Premium Incline Table (Table Only) +$499.00Premium Incline Table Entire Kit +$750.00Premium Flat Table (Table Only) +$400.00Premium Flat Table Entire Kit +$650.00Economy Maxx Table (Table Only) +$350.00Economy Maxx Table Entire Kit +$600.00Economy Aluminum Table (Table Only) +$350.00Economy Aluminum Table Entire Kit +$600.00Exam Table (Table Only) +$300.00Exam Table Entire Kit +$450.00Premium Massage Chair (Chair Only) +$300.00Premium Massage Chair Entire Kit +$650.00Economy Massage Chair (Chair Only) +$300.00Economy Massage Chair Entire Kit +$450.00Desktop Portal +$195.00Hot Towel Cabinet +$279.00Rolling Stool +$90.00Folding Chair or Trolley +$50.00Mattress Slide +$120.00Individual Body Cushion +$150.00Body Cushion Entire Kit +$450.00Face Rest Platform +$100.00Face Rest Pad (Table or Chair) +$80.00Face Rest Pad (Sleep System) +$80.00Premium Carry Case +$120.00Economy Carry Case +$80.00Sternum Pad +$80.00Economy Aluminum Table Entire Kit - 30% of rental buyout +$169.50

Notes

* Required Fields