Equipment Order Form

The best face down recovery equipment rentals for macular hole repair & vitrectomy recovery.

We will call within 24-hours to confirm details of order. Please call if you need to order sooner.

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Name
Address Line 1
Address Line 2
City
State
Zip Code
Address Line 1
Address Line 2
City
State
Zip Code
Length of Rental
Does anyone in the household smoke?

We will call within 24-hours to confirm details of order. Please call if you need to order sooner.

SHIPPING:  Ground shipping to and from the patient’s home is included in the price of rental. When time allows equipment will be delivered two days prior to surgery for no charge. The rental begins the day of surgery and is counted in 24-hour periods, not calendar days. For example, if your surgeon has recommended face down positioning for seven days your rental will span over eight calendar days or seven 24-hour periods.  Once given the ‘all clear’ from positioning, simply call our office and we will schedule a driver to pick up the equipment. We send the return labels to the driver electronically. The driver will attach the label and take the box. NO ADDITIONAL FEE for pickup from the patient’s home.

RENTAL REFUND POLICY: Rental charges will be billed to the credit card on file on the day of shipment. If an order is cancelled prior to shipping, all rental fees will be refunded. If an order is cancelled after the equipment has shipped but the box is unopened, the rental fee will be refunded less the shipping charges, the cost of the box, and a $25 processing fee. If an order is cancelled after equipment has shipped and the box has been opened, the rental fee will be refunded less shipping charges, the cost of the box, and a $45 processing fee (clean, pack, order process).

ITEMS NOT RETURNED:  Items not returned will incur a replacement fee which will be charged to the credit card on file.
PLEASE NOTE: Item fees will be promptly refunded once items are returned.

DAMAGED EQUIPMENT:  Repacking videos are sent when pickup is scheduled. Replacement fees will be charged for damaged equipment due to improperly packed boxes. A restocking fee of $50 will be charged to the credit card on file or billed to the patient for any Non-Smoking equipment returned with the odor of smoke.