Bilirubin Lights – G’mach

At Bikur Cholim we understand that there may be unexpected medical costs with the arrival of a newborn. There are times when a pediatrician and or a mohel may find it necessary to remedy a high bilirubin level in order for a Bris to be performed at the appointed time. To help alleviate the financial hardship associated with this expense, Bikur Cholim subsidizes the use of bilirubin light blankets arranged through Bili Blanket LLC.

Parent/Baby Address

1. Street Address
2. City
3. Zip Code
Use a different address for shipping/delivery

Parent Details

4. Salutations
5. Mother First Name
6. Father First Name
7. Last Name
8. Mother Mobile Number
9. Father Mobile Number
10. Mother Email Address
11. Father Email Address

Baby Details

12. Baby Legal First Name
13. Baby Legal Last Name
14. Baby Date of Birth

Pediatrician Details

15. Pediatrician First Name and Last Name
16. Pediatrician Phone Number
17. Pediatrician Email Address

Mohel Details

18. Mohel First Name and Last Name
19. Mohel Phone Number
20. Mohel Email Address

21. TERMS & AGREEMENT

I understand and agree that the contract and all liabilities regarding the use or non-use of a bili blanket and any related components are between me (the Parents) and Bili Blanket Baby LLC.

I understand and agree to all terms and conditions in the Bili Blanket Baby LLC Equipment Lease Agreement And Disclosures Document.

I understand and agree to indemnify Bikur Cholim from any claims and any and all potential liabilities that may arise from use or non-use of the bili blanket.

I understand and agree that any questions regarding use of the bili blanket are to be directed only to Bili Blanket Baby LLC who can be reached at (877) 593-2454 every day from 7:00 AM – 7:00 PM. Additional information can be found at www.biliblanketbaby.com.

I understand and agree that a pediatrician prescription is required to be submitted to Bikur Cholim by email at info@bikurcholim.net or fax (323) 852-0727 for delivery of the bili blanket and that it is my (the Parents’) responsibility to contact Bikur Cholim to confirm its receipt of the prescription. Prescriptions must be received by Bikur Cholim no later than 1:00 PM Sunday – Friday in order to arrange for same-day delivery.

I understand that when I (the Parents) receive notice from my pediatrician’s office or the Mohel that I am able to discontinue phototherapy treatment for my baby, it is my (the Parents’) responsibility to immediately have my pediatrician (or a signed AMA on file) send Bikur Cholim a STOP ORDER before the day of the bris to info@bikurcholim.net or by fax at (323) 852-0727, or my credit card will be charged $125 per day until its return. Stop Orders may be submitted Sunday – Friday between 10:00 AM – 3:00 PM PST.

I understand and agree that I (the Parents) will be responsible to reimburse Bikur Cholim for any charges and costs incurred due to my (the Parents’) failure to notify Bikur Cholim in writing of the Stop Order.

I understand and agree that the rental period will only end when the bili blanket and associated components have been returned to Bili Blanket Baby, LLC. Bili blankets and related components may not be returned to Bikur Cholim. A shipping box and label will be provided to me for the return.

I understand and agree that I will be required to provide Bikur Cholim a credit card deposit at the time of order confirmation.

22. Parent Signature

By providing your digital signature below, you agree to all of the above terms and conditions set forth by Bikur Cholim and Bili Blanket LLC.


Signature


Today's Date

Thursday, August 18, 2022


Once you have submitted this form, you must call us at (323) 852-1900 to confirm our receipt of your request.









Bikur Cholim