Rental Agreement Contract:

RENTAL AGREEMENT FORM: #__________

a. Daily   Lactina® Breast pump Rental
Total   Lactina® Breast pump Rental Days at $_______/day = $_______________

b. Monthly   Lactina® Breast Pump Rental (____)
______months @ $_________/mo = $________________

c. Additional items
Lactina® Breastfeeding Accessory Kit $_________________

Sales Tax @_________% $__________________

Grand Total $___________________

BABY MANIA Lactina® Breast Pump Rental Amount received in full

Date______________   BABY MANIA Breast Pump Rental Station Signature____________________

Lessee Information:

Full Name ____________________ First Name/Husband_________________

Street ________________ City ______________State/Zip________________

Phone______________________

Driver's License ___________________________

Social Security____________________________

Dr's name and address:______________________________________

Lessee and BABY MANIA Breast Pump Rental Station agree with the Breast Pump Rental Conditions

Lessee Signature___________________________________

PLEASE PRINT THE CONTRACT AND FAX TO:
817-297-9399

Baby Mania Medela Breast Pump Rentals

{Rental Agreement} {Rental Contract} {Rental Equipment}

For Personalized Customer Service Call Today!

Baby Mania

Medela Breastpumps, Medela Lactina Select Breast pumps, Medela Symphony Breast pumps and the Medela Limited and Metro Advanced Breast pump, and Medela Breast pump and breastfeeding Accessories.

Fort Worth at 817-297-9399

PLEASE CALL US ANYTIME....WE WILL BE HAPPY TO HELP YOU......THE CUSTOMER IS #1....