AUTHORIZATION AND NOTICE OF FINANCIAL RESPONSIBILITY

Any abuse or damage which incur repair fee(s) will be charged to the renter in accordance with this rental agreement.

$40/day late fee will be incurred post rental end date.

If the product is not returned within 5 business days and no notification of rental extension has been given, A one-time $5000.00 will be charged to the credit card as detailed below.

PATIENT SIGNATURE, PERSONAL REPRESENTATIVE or RESPONSIBLE PARTY SIGNATURE

By signing below, I agree to the terms and fees set forth above and authorize to charge my credit card for the charges specified above as well as for the charges for subsequent services that may incur as detailed above.