Medical Equipment Form

PLEASE CALL OUR OFFICE BEFORE COMING TO OUR SITE FOR MEDICAL EQUIPMENT TO ENSURE WE HAVE IT AVAILABLE. THANK YOU.

MEDICAL EQUIPMENT LOAN

Release and Hold Harmless

In consideration of being allowed to use certain medical equipment from the Pawling ResourceCenter I agree as follows:

That the equipment being loaned to me has not been professionally examined or inspected, therefore it is being loaned to me in “as is” condition and I hereby assume the risk of loss or personal injury or property damage resulting from its use.

I, (as well as my heirs, executors, and assigns) do release, indemnify and forever discharge andhold harmless, the Pawling Resource Center (and its agents, officers, employees and assigns), from any and all liability, loss or damage whatsoever, arising from use or possession of this equipment.

I agree to use this equipment only for the purposes for which it is intended.

IN WITNESS WHEREOF, I have here unto set my hand(s) and seal(s) this. You will be required to sign this form before borrowing equipment

Today's Date

Your First Name

Your Last Name

Name of person using equipment

Multi-line address

Country/Region

Address

City

Zip / Postal code

Cell Phone

Home Phone

Name of person picking up equipment

If you need a hospital bed or associated equipment or chose the "other" checkbox, please indicate what equipment you are looking for below and call our main office at 845-855-3459 and leave a message on our voicemail.

Release & Hold Harmless

In consideration of being allowed to use certain medical equipment from the Pawling Resource Center I agree as follows: That the equipment being loaned to me has not been professionally examined or inspected, therefore it is being loaned to me in “as is” condition and I hereby assume the risk of loss or personal or personal injury or property damage resulting from its use. I, (as well as my heirs, executors, and assigns) do release, indemnify and forever discharge and hold harmless, the Pawling Resource Center (and its agents, officers, employees and assigns), from any and all liability, loss or damage whatsoever, arising from use or possession of this equipment. I agree to use this equipment only for the purposes for which it is intended. By typing your name below you acknowledge that you understood this statement and will abide by it.

Typing your name below will constitute as a signature agreeing with the statement above

Medical Equipment Form

Physical Address: 126 East Main Street,
Pawling, NY 12564
Mail Address: P.O. Box 331, Pawling NY 12564
Phone 845-855-3459
Email: info@pawlingresourcecenter.org

HOURS:
Monday-Friday 10am-4pm,
(NOW Open Wednesdays from 10 am to 5 pm)
and the 2nd Saturday of each month from 10am-12pm