Financial Responsibility Form

Name

the person above agrees to be financially responsible for charges incurred for the rental of specialty medical equipment from Ergo Midwest, Inc. Financial responsibility is absolute and unconditional.

Patient Name

Patient Residing at

Equipment Provided

Daily Per Diem Charge

E-Signature

By typing my name as the electronic signature, Responsible party named above agrees that Ergo Midwest, Inc retains all ownership rights to the equipment. Responsible party named above agrees to notify Ergo Midwest, Inc to pick up said equipment when it is no longer needed and may do so at any time without penalty. Delivery and pick up fuel surcharges may apply.

Date

Financial Responsibility Form