Medical Equipment Free Loan – G’mach

Bikur Cholim’s Medical Equipment G’Mach loans out free medical equipment to patients and families of all ages. Wheelchairs, walkers, crutches, and all types of medical supplies are available at no cost for those leaving the hospital, recovering at home, or any emergency.

What item(s) are you requesting?

Please select at least one item below:

Item 1:
Item 2:
Item 3:
Item 4:
5. When would you need to pick up said item(s) from our office? (MM/DD/YYY)
6. When do you expect to return said items(s) to our office?
8. Salutation *
9. First Name (As per your ID) *
10. Last Name (As per your ID) *
11. Gender *
12. Address *
13. City *
14. State *
15. Zip Code *
16. Home Phone *
17. Mobile Phone *
18. Email *

Person using requested item(s):

References

19. Who and/or what agency referred you to Bikur Cholim? *
20. Synagogue/Organization affiliation *

Personal reference

21. Salutation *
22. First Name *
23. Last Name *
24. Phone Number *

25. Person picking up item(s) from our office:

26. TERMS & AGREEMENT

It is our pleasure to make this equipment available to you. By submitting this form you agree to the following:

  • Please safeguard item(s) from any misuse. Never leave item(s) outside exposed to the elements when not in use.
  • All items are loaned in clean/operable condition. Please ensure all items are returned to us in the same clean/operable condition in which they were picked-up. Items returned in damaged and/or unclean condition will be subject to a replacement/cleaning fee.
  • This item(s) is being loaned to you based upon your agreement to waive and release any/all rights and claims against Bikur Cholim for injuries sustained and/or caused while using this no-cost loaned medical equipment. If you are not in agreement with the aforementioned, cease using said equipment and return it to our office immediately.
  • Once this item(s) is no longer medically necessary, please call us to schedule a time for you to return it to our office. Please do not attempt to return any item(s) without a scheduled appointment Bikur Cholim personnel must take receipt of any returned item(s). No item can be left unattended at our building or with non-Bikur Cholim personnel.
  • Any violation of the above terms and conditions may result in a $250 fee.
I agree to the terms above.








Bikur Cholim