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Home
About Us
Who We Are
Our Team
New Patients
Medical Consultations with Dr Hayter
Nutrition Consultations with Sonya Cacciotti
Advisory Consultations with Dr Hayter
Client Information
Making an Appointment
Scripts and Referrals
Obtaining Test Results
Reminder System
Test Requests
Contacting Our Practitioners
Telehealth Appointments
Payment
Cancellation Policy
Fee Structure
Make an Appointment
Webinars
Shop
Contact
Rental Agreement
"
*
" indicates required fields
Name
This field is for validation purposes and should be left unchanged.
This is a rental agreement between Ballina Health Centre, 32 Tamar Street, Ballina NSW 2478 and myself
Name
*
First
Last
of
*
Street Address
Suburb
State
Postcode
Date of Birth:
*
Please enter your date of birth in the format DD/MM/YYYY
Email:
*
For the rental of:
You may tick more than one.
*
NOX Sleep Monitor $200 per night (return tomorrow morning)
Apnealink Sleep Monitor $100 per night (return tomorrow morning)
MediLog Holitor $100 per night (return 24hrs after starting)
24 hour Blood Pressure Machine $100 per night
Blood Pressure Machine $20 per night
I understand:
*
that if the equipment is damaged, stolen or not returned that I am responsible for the reparis or replacement in addition to any extra hire fees
I understand
*
hire fee is fixed at rate detailed above, there are no refunds for early returns and hire costs are applicable regardless of if the equipment has been used or not
I understand
*
where equipment is kept past it’s return date, a further rental fee will be deducted from my supplied credit card
I understand
*
in the event of a debt recovery agent being engaged to retrieve goods/payments due to of this agreement, agent recovery costs of up to $10000 may be passed on directly or indirectly to me in addition to the monies owing on my account and the replacement value of the goods
I understand;
*
All equipment must be returned as supplied including where applicable manuals/power leads/bags/battery pack backs etc. Any of these missing parts will be charged at replacement cost
Date borrowed:
*
DD slash MM slash YYYY
Date to be returned:
*
DD slash MM slash YYYY
Please sign:
*
Patient Declaration
*
I understand the above and I am aware that if the equipment is not returned by the due date, my credit card will be charged accordingly as per the above rental agreement.
Please leave your Credit Card details with reception.
Details with reception staff?
*
Yes
No
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