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Ameda Pearl Rental Agreement
Powerful: Hospital Grade Performance with two modes of pumping

Portable: Lightweight with rechargeable battery and integrated handle

Comfortable: Fully customizable expression mode with 72 possible combinations of speed and suction settings.
Some insurance plans cover the rental cost of the Ameda Pearl. A prescription is required to go this route. Would you like us to check benefits after you submit the form?*

YesNo
Please upload your prescription*

Cancelof
Front picture of insurance card*

Cancelof
Back picture of insurance card*

Cancelof
Whether or not your insurance covers the rental of the pump it may cover storage bags, bottles, flanges and tubing or some combination of those. If these items are covered, would you like them shipped to you at the frequency your insurance allows? ***Typically every 1-3 months****

YesNo
Thanks for the response, we will just send out the intial set of covered items to get you started, if you change your mind, please don't hesistate to reach out to us.
Full Name*

First NameLast Name
Due Date or Child's Date of Birth*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
E-mail*
example@example.com
Contact Number*
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Name*

First NameLast Name
Physician Phone Number*
You have 2 choices for renting this pump, most mom's elect 6 months, but the choice is yours! All rental sales are final and there are no refunds for returning early. As a courtesy, we will reach out to you and remind you when pump is due along with sending you a prepaid label to ship it back. If you desire to extend another 3 months, it will be billed for $300. If your insurance covers the rental, we will refund you within 14 business days of shipping the pump.*
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3 month rental
$300.00



6 month rental ($50 off!)
$550.00



Ameda Pearl Purchase
$849.00 Quantity



Total

$0.00
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Ameda Pearl Rental Agreement