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Portable Oxygen Concentrator Rental

Thank you for choosing Vienna Medical as your portable oxygen concentrator source. Fill out the online rental form below to secure your POC rental today. Your credit card will be charged the entire amount of your rental including shipping and a refundable security/damage deposit of $300. Our second option is to print and fax your rental form and credit card authorization form. This second option allows for your credit card to be charged a deposit amount of $50 for your rental and the remainder to be charged at time of rental. Call customer service should you have any questions. 1-800-489-8165 (Credit card authorization and rental forms found here)

TO RENT A P.O.C. BATTERY ONLY PLEASE CLICK HERE!

FOR PRESCRIPTIONS - You may fax your Oxygen Prescription to 386-753-1949 or email a digital file to viennamedical@cfl.rr.com. All POC rentals require a valid prescription.

Patient Information

All Fields In BOLD Are Required

Patient's Legal Name: D.O.B.: Sex:

Height: Weight: Diagnosis: Liter Flow:

Contact Phone # During Rental:

Emergency Contact Name:

Emergency Contact Phone #:

Physician Information

**We must have the existing O2 prescription faxed to us prior to dispensing Oxygen**
You may call the physician and have him/her fax the order to 386-753-1949

Physician's Name:   Address:

City:   State:   Zip:

Phone #:   Fax #:

Additional Shipping & Billing Info To Be Added At Checkout

Rental Details

ALL ITEMS MUST BE RETURNED CLEAN AND IN
ACCEPTABLE CONDITION AS WHEN FIRST RENTED.

Start Date:   Number Of Days Of Rental*:

* $225 for the first 7 days - $25 a day after that. Rental begins on the date requested and ends the day you ship it back to us. Unit must be received back within 5 days or the daily rate will apply (California, Washington, Hawaii - 7 days).

For rental periods over 1 month please call us at: 1-800-489-8165.

Select A Portable Oxygen Concentrator*:

Not sure which POC is best for you? Click Here >> Portable Oxygen Concentrator Comparison

* Includes complete ready to use system with all chargers, tubing, carrying bags and two charged batteries.

Add Extra Batteries If Desired
Extra Batteries are $50 for the first 7 days - $8 a day after that. Check off each battery desired.
Be sure to specify number of days per battery.

    Extra Battery 1    Number Of Days For Extra Battery 1:

    Extra Battery 2    Number Of Days For Extra Battery 2:

    Extra Battery 3    Number Of Days For Extra Battery 3:

    Extra Battery 4    Number Of Days For Extra Battery 4:

    Extra Battery 5    Number Of Days For Extra Battery 5:

PLEASE READ AND AGREE TO TERMS

Terms: Initial rental is due along with any other applicable charges and a $300 Security Deposit before delivery can be made. If an extension is needed we must have at least a 72 hour notice. An additional week or daily rate of rental begins the following day after your initial week of rental should it not be returned on scheduled date. Rental on equipment starts the day the equipment is received in home or is picked up and stops when the equipment is shipped out from your location or dropped off.

The Customer is responsible for replacement costs of damaged, missing or permanently stained rental equipment. WARNING: Florida statute 812.021 sub section 7 provides that failure to return rented equipment as agreed at time of rental is considered prima facie evidence of larceny and will be prosecuted. In the event Shenk Enterprises, LLC. d.b.a. Vienna Medical institutes legal proceedings to recover missing property or damages arising from the contract, we will be able to recover Legal fees along with any additional costs to damaged equipment. Test and (or) Repair Charges - If returned equipment appears broken due to misuse, a test and repair charge of $50.00 may be charged for inspection, testing and minor repairs required to return the Equipment to service. This charge will be payable at the end of this agreement. If the equipment cannot be repaired, the customer will be notified and will be responsible for the designated replacement cost of the Equipment.

Shipping is $75 (This covers the item to be shipped ground to the patient and back to us) A paid delivery tag will be included with the unit when shipped. Simply use the same box, put the new delivery tag on it and ship. Additional shipping & billing info to be added at checkout

Security Deposit - $300 for domestic travel*, fully refundable upon undamaged return of unit.
*For international travel please call us at 1-800-489-8165

Limitation of Liability and Indemnity:
Limitation of liability - In no event will Shenk Enterprises, L.L.C. or Vienna Medical be liable to the Customer for any Incident or injury, indirect or consequential damages however caused, whether by negligence or otherwise relating to renting or using any medical equipment.

Indemnity - The Customer agrees to protect, indemnify and hold harmless Shenk Enterprises, L.L.C. from and against all claims, damages and costs including legal expenses arising out of Customer's use of the equipment.

By checking the box below and submitting you are stating that:

I agree that I have been instructed on how to use the equipment and take full responsibility for the proper use and care of the equipment during the rental period so that it is returned in the same condition as when received.

I fully understand that I am responsible for any and all damages and therefore repair costs that may arise from use of the product during my rental period.

You will be contacted within 48 hours for a verbal confirmation.

BEFORE SUBMITTING PLEASE MAKE SURE ALL REQUIRED FIELDS ARE FILLED OUT AND ALL INFORMATION IS CORRECT!

Any Additional Comments:

I have read and agree to all terms.

Quantity:

vienna medical

Portable Oxygen Concentrator Rental

TO RENT A P.O.C. BATTERY ONLY PLEASE CLICK HERE!

Patient Information

Physician Information

Rental Details