Print this form and fax it to: (604) 939-0436

Name:

Street/Mailing Address:

City:

Province:

Postal Code:

Phone (home):

(work):

(cell):

Email address:

Choose Rental Term:

  ( ) Month-to-month      ( ) 2 month pre-paid      ( ) 3 month pre-paid

  ( ) 4 month pre-paid    ( ) 5 month pre-paid      ( ) 6 month pre-paid

Would like to purchase a personal listening earpiece (these items are not standard issue with rentals)? COST is $4.69 (plus GST):

  ( ) Yes         ( ) No

Credit Card:

VISA

MASTERCARD

Name as it appears on card:________________________________________

Number:________________________________________________________

Expiry Date:_____________________________________________________

By rental of the Fetal Doppler Monitor you are accepting the terms and conditions of rental as outlined below.

You are responsible for discussing the use of this product with your health care provider. Dopplers to Diapers Ltd. Assumes no liability or responsibility for any difficulties that may occur in relation to the use of the Fetal Doppler Monitor.

To rent the Dopplers to Diapers Doppler Monitor you will be charged: the current rental price/month plus applicable taxes - charged to the credit card number given. When renting the unit, the initial charge to your credit card will be made on the day the unit is shipped. Recurring charges will be made on the same day each month thereafter until the unit is returned or purchased. When returning the unit, please contact us via telephone or e-mail and charges will be held for 48 hours past the billing date. Rental fees are not pro-rated. All rental fees from current rental apply toward the purchase price of the unit.

Warranty: Dopplers to Diapers warrants that the Fetal Doppler Monitor will perform to standard specifications during the rental period. Dopplers to Diapers will replace any unit that fails during the rental period. However, if the unit is damaged by misuse, neglect or accident, the customer assumes full liability for repair or replacement costs. If the unit is stolen, lost, or destroyed, the customer will be charged the full price of the unit: $650.00 CDN (plus GST) for the Fetal Doppler Monitor.

Returns: Upon receiving the Fetal Doppler Monitor, if you are not completely satisfied, Contact us at 1- 866 - 210 - 1633 and return the Fetal Doppler Monitor to Dopplers to Diapers Ltd. within 5 days for a refund (except for the shipping and handling fee). When you are ready to return the Fetal Doppler Monitor, please follow the enclosed return instructions and return the Fetal Doppler Monitor in its original shipping container to Dopplers to Diapers Ltd.