*Providers please do not use this form. This is for the family to fill out. Please see How to Order above for more info.*

Do you have coverage through one of the following providers?

Please choose the option that represents your baby’s medical insurance coverage, understanding your baby is likely not yet enrolled.
$395.00

Temporary Authorization/Hold Requirement: To qualify to rent a biliblanket, the renter must present a valid major credit card or debit card with available credit. At the time of rental, an authorization hold of $395.00 will be secured on the credit/debit card provided, to cover the estimated rental charges that may be incurred. These funds will not be available for your use. Your final billing details will be determined after the equipment is returned.

$395.00

Autorización temporaria/Requisito de retención: Para calificar al alquiler de un biliblanket, quien alquila debe presentar una tarjeta de crédito o débito válida con saldo disponible. Al momento del alquiler, se asegurará una retención de autorización de $395,00 en la tarjeta de crédito o débito proporcionada para cubrir los costos estimados del alquiler en los que se pueda incurrir. Estos fondos no estarán disponibles para su uso.

You have the option to purchase a damage waiver for a one time upfront fee of $35.00 which covers unintentional damage to the Equipment during the Rental Period. Please see your completed Equipment Lease Agreement and Disclosures Document for additional details.

You have the option to purchase a damage waiver for a one time upfront fee of $35.00 which covers unintentional damage to the Equipment during the Rental Period. Please see your completed Equipment Lease Agreement and Disclosures Document for additional details.


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