Clinics Can Help

Resources

Please fill out this form below, submit to open a printable page, or download this form and print. You
will need to bring it with you when you come to our West Palm Beach office.

Client Name:	Client #:
Street Address:	Date:
City: State: Zip:	Phone:
How did you hear about us?:	Date of Birth:
Email:	Ethnicity:
Name of Person Responsible for Equipment:	Relationship to Client:
Street Address:	Home Phone:
City: State: Zip:	Work Phone:
Two Nearest relatives, friends, or advocates NOT LIVING WITH the client (REQUIRED)
Name:	Name:
Relationship:	Relationship:
Address:	Address:
City: State: Zip:	City: State: Zip:
Phone:	Phone:
Expected Length of Need:	1 month 3 months 6months other
Equipment on loan (to be filled out by CCH) ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ I acknowledge that the above-identified equipment was inspected by me, or my advocate, and at the time I received the equipment it was clean and in good condition. I agree that I will return the equipment in the same condition. I agree that I will immediately return this equipment when my present physical need no longer exists. I will not permit this equipment to be transferred to another person under any circumstances, and while this equipment is in my possession, I will notify you of any change of address for me. I will not take this equipment out of the area served by Clinics Can Help I hereby release and hold harmless Clinics Can Help, its members, agents, or employees from any claim by me, or any person acting for me or on my behalf for any loss, expense, or damage, including but not limited to general, specific, incidental, or consequential damages, of any kind or nature whatsoever arising from this equipment or its use. I agree that Clinics Can Help, its members, agents, or employees have made no representation of any kind whatsoever, express or implied, to me with regard to the condition of the equipment provided or as to the use to which the equipment is to be put. I also give Clinics Can Help permission to take my photo and to use it in any and all promotional venues. Signature of Client/Advocate _____________________________ Date _____________ Please return equipment to: * Clinics Can Help 1550 Latham Rd Unit #10 West Palm Beach Fl.33409 *phone: (561) 640-2995 fax: (561) 640-1881