Single Point Cane

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I hereby acknowledge receipt of the selected medical equipment loaned for the Applicant’s sole use. This equipment will not be provided, given or loaned to anyone else. I acknowledge that I have received information regarding proper and accepted use of the equipment, and I affirm that I will only use it for its intended, designed use. I will comply with weight restrictions, safety guidelines and appropriate use, as designated by the referring medical provider, and I will exercise ordinary and reasonable care. I acknowledge that I have examined the equipment and that I find it in good condition and fit for its intended use, I promise to return the equipment by the notated date and in consideration of future borrowers, I promise to clean and sanitize the equipment prior to returning it. I understand that the equipment loaned through the Durable Medical Equipment Loan Program remains the property of Methodist Health System. Equipment available through the Durable Medical Equipment Loan Program has been used prior to loan for patient use. The equipment is “as is” and structural integrity of the loaned equipment is not guaranteed. If equipment is found to be damaged or needs repair, Applicant will contact the Durable Medical Equipment Loan Program immediately to return damaged equipment. I hereby forever release, waive and discharge Methodist Health System, its affiliates, subsidiaries, insurers, successors, directors, employees, agents, and representatives from all liability, claims, demands, and actions I may have for any personal or bodily injury, illness, death, or property damage, now known, or that be made known in the future, resulting from use of the loaned equipment. Further, I hereby assert Methodist Health System will not be held responsible for any defect in the equipment. I acknowledge and represent that I have read the foregoing Release, Waiver of Liability and Hold Harmless Agreement, understand it, and sign it voluntarily as my own, free act and deed; no oral representations, statements, or inducements apart from the foregoing written agreement have been made; I am at least nineteen (19) years of age and fully competent (if not nineteen, my parent(s) or guardian(s) agree with the terms of this document and sign it as such); and I execute this Release for full, adequate, and complete consideration fully intending to be bound by same.

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