Rent Medical Equipment

Rental equipment can be rented and reserved by the week or month, depending on the item. We require three days advance notice to ensure availability of your equipment or delivery for larger equipment if needed.

If you require equipment within the next three days, please call us at 406-587-0608.

Your Information

First Name*

Last Name*

Date of Birth (MM/DD/YYYY)*

Age*

Gender

Email*

Contact Phone Number*

Home Address*

Address Line 2

City*

State*

State

Zip Code*

Insurance Card

Upload an image of your insurance card or bring it to your appointment.

Medical Equipment To Reserve (Choose up to 4)*

CPM: $105 /week

Wheelchair: $35 /week

Transport Chair: $30 /week

Knee scooter (rollabout): $30 /week

Motorized scooter: $150 /week

Hospital Bed (semi electric): $175 /month

Hospital Bed (full electric): $225 /month

Portable oxygen concentrator: $150 /week

There is a four day lead time for all rental requests.

Start Date (MM/DD/YYYY)*

End Date (MM/DD/YYYY)*

Rental Agreement/ Privacy Practices Acknowledged

I am aware that Price Rite Medical Equipment, Inc. makes best efforts to provide its equipment in good working order and I am responsible for all losses and damages while the equipment is in my possession. I acknowledge that I have inspected the equipment, it is in good condition and I accept the equipment AS-IS without any warranty. I understand that the title to the equipment shall be retained at all times by Price Rite even while I am renting said equipment. I have not signed any purchase agreements with Price Rite. I have not authorized Price Rite to bill my insurance company unless stated above. I understand that rental of the said equipment is based on cash terms at the time of return or on demand by Price Rite. I acknowledge that if I do not return or pay rent for the equipment that Price Rite may take action including filing a lawsuit against me to recover all damages allowed by law or by physically recovering the equipment from me and recovering all unpaid charges with initial form of deposit stated on this agreement. I agree to pay Price Rite’s attorney’s fees and all costs if it is forced to take action against me. In addition, I have received a copy of the Notice of Privacy Practices and been given a chance to review it

Signature (type your full name)*

Date

Request Equipment

Rent Medical Equipment

Your Information

Rental Agreement/ Privacy Practices Acknowledged

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