Please download and fill the following form for any rental. For your convienence two file format have been provided for you, Microsoft Words and Adobe PDF
You will need Adobe Reader to view the PDF files. Get the lastest Adobe Reader by clicking on the Download button below.
You may either fax the form back to us at 1.866.866.3534
or mail it to us at
Express Medical Supply, Inc
6521 Arlington Boulevard Suite #205,
Falls Church,
VA 22042
Phone: 1.866.691.3511
Fax: 1.866.866.3534
The mobility equipment / rental product is the property of Express Medical Supply and is in good condition. Renter will return the mobility equipment in the same condition as when received to Express Medical Supply, at the end of the rental period for inspection and recharge of battery (if necessary), or sooner, upon the demand by Express Medical Supply.
Equipment are not allowed to be removed out of the rental area , here as defined Maryland, Virginia and Washington D.C.
An additional delivery and service fee charge will be charged for all deliveries of 5 miles radius minimum $15.00 one way. All deliveries outside this radius will be charged additional $0.75 per mile. All equipment rentals with a pickup/delivery location greater than 20 miles require a 2 day minimum rental agreement.
Lost or stolen equipment(s) is Renter’s responsibility. Renter’s credit card will be billed the amount for repair/replacement of equipement.
Renter assumes all risk of such loss or damage and waives all claims against Express Medical Supply by reason thereof and Renter agrees to hold Express Medical Supply harmless from and to defend and indemnify Express Medical Supply against all claims based upon or arising out of such loss or damage. Renter assumes all risk and liability for any loss, damage or injury, including death, to persons or property of Renter or others arising out of the use, operation or driving of the mobility equipment.
The additional conditions outlined above have been reviewed and accepted as part of this agreement.
Renter shall notify Express Medical Supply immediately of any and all accidents and damage resulting from the use, operation or driving of the mobility equipment.
Renter shall require drivers to operate the scooter with reasonable care and diligence and comply with the terms of this agreement.
Rental agrees to pay all costs, expenses, and attorney’s fees incurred by Express Medical Supply in collecting sums due or in regaining possession of mobility equipment or in enforcing or recovering any damage, losses or claims against Renter.
Renter or the driver of the mobility equipment shall in no event be deemed the agent or employee of Express Medical Supply in any manner or for any purpose whatsoever.
Any individual executing this Agreement as Renter in a representative capacity shall be bound personally, jointly and severally, with such fiduciary, corporation or other entity as to all obligations, expressed or implied, arising hereunder.
This Agreement shall be binding upon the distributees, heirs, next of kin, executors, administrators and personal representatives of the undersigned Renter.
If any provisions hereof or the application of any provisions to any person or circumstance is held invalid or unenforceable, the remainder hereof and the application of such provision to other persons or circumstances shall remain valid and enforceable.