DME Checkout Form

Use this form to checkout durable medical equipement from CMAP's Lending Locker.

First Name*
Last Name*
Email*
Phone*
Street Address*
City*
Address (State)*
Zip/Postal Code*
Select the item(s) you are checking out from the dropdowns below. If your item isn't listed, choose "Other":*
Please add any additional or unlisted items here:
To check out items from the CMAP Lending Locker, you must agree to the DME Liability Release Waiver.
I have reviewed the DME Liability Release Waiver and accept the terms*
CMAP allows permanent loans of its lending locker equipment in certain circumstances. Please indicate whether you intend to return the item(s) you are checking out, and if so, what approximate date you anticipate returning them.
Anticipated Return Date (if applicable)
This is a permanent loan
Additional Checkout Details
First Name
Last Name
Email
Phone
Street Address
City
Address (State)
Zip/Postal Code
Select the item(s) you are checking out from the dropdowns below. If your item isn't listed, choose "Other":
Please add any additional or unlisted items here:
To check out items from the CMAP Lending Locker, you must agree to the DME Liability Release Waiver.
I have reviewed the DME Liability Release Waiver and accept the terms
CMAP allows permanent loans of its lending locker equipment in certain circumstances. Please indicate whether you intend to return the item(s) you are checking out, and if so, what approximate date you anticipate returning them.
Anticipated Return Date (if applicable)
This is a permanent loan
Additional Checkout Details

609.751.9699