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Client Information

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Description of Equipment

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Are You Using This Device For?

Client Name(Required)

Client Phone(Required)

Client Email(Required)

NRIC Address(Required)

Block Street Name Floor Unit Postal Code Country

Collection of Client's Data

For validating the client’s identity and creation of the rental agreement, the client will have to upload either:

A copy of your NRIC (Front & Back) / Singpass indicating the name and address(Required)

Drop files here or

Max. file size: 5 MB, Max. files: 2.

Client's Full NRIC Number(Required)

Is the Client and the Patient the Same Person?

Yes

Patient Name(Required)

Patient's Full NRIC Number(Required)

Delivery Options

Delivery Options(Required)

Delivery Options

Delivery Options(Required)

Where Would You Like Us to Deliver to?

Delivery Address(Required)

Same as NRIC Address

Block Street Name Floor Unit Postal Code Country

Rental of

Administrative Charge (One-Time Charge)

Administrative Charge(Required)

Price:

Administrative Charge (One-Time Charge)

Administrative Charge(Required)

Price:

Administrative Charge (One-Time Charge)

Administrative Charge(Required)

Price:

Administrative Charge (One-Time Charge)

Security Deposit(Required)

Price:

Delivery Charges

Delivery Charge

Add-On

Price: $0.00

Total Estimated Cost

Total

Equipment Rental & Sale

Other Services

Contact Us

Email:

Oxygen Concentrator Rental Form

Client Information

Collection of Client's Data

Delivery Options

Delivery Options

Where Would You Like Us to Deliver to?

Do you require any additional consumables ?