"*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Please fill out the form below. You will be contacted within 24 business hours by one of our Patient Service Representatives to complete your order for vitrectomy surgery recovery equipment.Patient's First Name*Patient's Last Name*Contact Name (if not patient)Email Primary Phone*Alternate PhoneDelivery Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Address* Same as Delivery Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth (mm/dd/yyyy) MM slash DD slash YYYY Date of Surgery (mm/dd/yyyy)* MM slash DD slash YYYY SurgeonOffice/Practice NameExpected Length of RentalPackageVitrectomy Max Comfort PackageVitrectomy Essential PackageVitrectomy Economy PackageI would like help selectingOtherTerms & Conditions* I agree to the Terms & Conditions.• McFee Medical Technologies/OWL Leasing, Inc. no longer offer a refund once the equipment has been shipped. Any cancellations made prior to shipping will not be charged. • It is my responsibility to report to McFee Medical Technologies/OWL Leasing, Inc. any damage beyond normal wear and tear or missing items immediately upon receipt of shipment to avoid any lost item charges. • It is my responsibility to ensure that McFee Medical Technologies/OWL Leasing, Inc. receives all of the contracted rental equipment after the agreed upon rental period or I will be charged the rental fee for each day the equipment is not returned (this means I must notify McFee Medical Technologies/OWL Leasing the DAY I want my rental to be ended). McFee Medical Technologies/OWL Leasing, Inc. recommends that you contact the shipping company identified on the yellow equipment return instruction card located in your rental equipment boxes prior to your rental completion date for timely arrangements and policy compliance. • A restocking fee of $100.00 per box 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. • If I do not return the equipment to McFee Medical Technologies/OWL Leasing, Inc. fully assembled and in good condition, allowing for normal wear and tear, I will be charged a restocking fee accordingly. • The credit card I provided at the time of rental will be used to secure additional charges incurred due to late return or damaged equipment. • McFee Medical Technologies/OWL Leasing, Inc. makes no medical representations regarding the use of the equipment. • McFee Medical Technologies/OWL Leasing, Inc. is not responsible for any medical condition arising or resulting from any medical treatment, including without limitation; eye surgery rendered to me by a physician or qualified healthcare provider. • McFee Medical Technologies/OWL Leasing, Inc. is not responsible for any injuries/damages resulting from use of the equipment in a manner not intended. • Submitting this Online Reservation Form signifies acceptance of the Rental Terms and Conditions. I understand and authorize that my credit card will be charged before any commercial (or other) insurance claim can be filed per this agreement. The charges may also be listed under the following names: Marketplus Software, McFee Medical Technologies, or OWL Leasing.
