Standard Rental

• Full weeks only. No partial weeks.
• $395 for 10 days, includes Ground shipping delivery and pickup.
• $295.00 for each additional 10 days
• Price includes shipping to you and return shipping to Rx Stat.
• Deposit reserve $500.00 fully refunded if no damages or loss.
• All rental fees must be paid in advance.
• Rental fees will be applied towards purchase price if you decide to buy the unit.

Online Rental Agreement Below

Standard Rental Equipment

1. Portable Concentrator
       Inogen One G2. Pulse flow only
       Evergo. Pulse flow only
       Eclipse. Continuous flow and pulse flow

2. Do you understand the difference between pulse flow and continuous flow oxygen?
       Yes
       No

3. Do you sleep with a CPaP or BiPap?
       Yes
       No

4. What is your oxygen liter flow?
       1 2 3 4 5

Each standard rental includes the following

• 2 batteries for Eclipse, Evergo. 1-24 cell battery for Inogen G2.
• Carry bag if applicable
• Wheeled cart
• A/C, D/C power cords (cost basis, $100.00 each)
• Shipping delivery and pickup. (You are required to repack the unit in the shipping box)
• Cost price of Standard Rental package for replacement. $3500.00.

5. I acknowledge the standard rental package. Your Initial:

Additional options

6. Extra batteries $30.00 week 0 1 2 3 4 5 6 7 8 9 10 qty *Most airlines require at least one additional battery beyond scheduled flight time.

7. External charger $30.00 week Yes No

8. The loss of parts/damage insurance cost is $98.00 week with a $300.00 deductable. Note that this does not cover if entire unit is lost or stolen.
Yes, I want it.
No, I do not want it.
Initial

9. Value of batteries for replacement. $300.00 each. Your Initial

Agreement to Rent

By signing this agreement below, I (patient) agree to the rental terms and conditions as described by Rx Stat, Inc.

Terms and Conditions

Equipment is provided to patient in good working condition, free of any known defects at the time it leaves Rx Stat, Inc. In no event will Rx Stat, Inc. be held liable for any damages, including, but not limited to death and hospitalization, caused by equipment failure.
Oxygen equipment can fail and it is the patient's responsibility to maintain an emergency back up contact at their intended destination(s). Rx Stat, Inc recommends traveling with an oxygen prescription on the patient's person in case of an emergency.
Indemnity - The Patient agrees to protect, indemnify and hold harmless Rx Stat, Inc. from and against all claims damages and costs including legal expenses arising out of the patient's use of this equipment.
Warranty - Rx Stat, Inc. implies no warranty, either written or verbal, expressed or implied on the equipment rented. The equipment is suitable for normal operation at time it leaves Rx Stat, Inc's premises. Rx Stat, Inc. will not be held liable for equipment failure in any way. Flying with oxygen is subject to individual airline policy.
Deposit - Rx Stat, Inc. will not be held liable for any costs associated with equipment failure. The security deposit reserve will be held and used against any damage costs or losses incurred during the rental period. Failure to return any or all of the equipment will be charged against the reserve deposit.
Shipping - Standard rental includes shipping to and from patient. It is patient's responsibility to have System packed and ready for return shipment by return date listed below. Failure to return System will result in additional weekly rental charges or outright purchase based on cost price.
If patient chooses to purchase System after rental period, rental charges can be applied towards purchase price.
Cancelation - If the units ships prior to cancellation, you will be charged a $150.00 cancellation fee.

Agreement to Rent

By signing this agreement, I (patient) agree to the rental terms and conditions as described by Rx Stat, Inc. I agree to allow Rx Stat, Inc. to charge my credit card for rental charges and damage/ loss charges if needed.

	Rental Period	Start date End date Number of weeks
	Patient First Name
	Patient Last Name
	Email
	Primary Phone
	Alternate Phone
	Billing Address 1
	Billing Address 2
	Billing City
	Billing State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
	Billing Zip
	Emergency Contact that is not traveling with you.
	Name
	Phone Number
	Is your Shipping Address the same as your Billing Address? (Click to automatically copy Billing Address to Shipping Address)
	Shipping Address1
	Shipping Address 2
	Shipping City
	Shipping State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
	Shipping Zip
	Name on Credit Card
	Credit Card Type	Visa American Express MasterCard Discover
	Credit-Card No.:
	CCV No.:	3 digit number on back of Visa, M/C. 4 digit number on front of American Express
	Expiration Date	Month: January February March April May June July August September October November December   Year 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
	Who is your primary insurance carrier?		Make a Selection Medicare Other
	By typing your name, this is an Electronic Signature binding you to this agreement just like an actual signature.
	Full Name: Date:
	Yes, please send me further communications from RxStat.