Help SA & Bhaitun Khair Medical Equipment Borrow
Please provide the information for the person responsible for the equipment.
Email address *
Full Name *
Your answer
Phone number
Your answer
Cell Phone number *
Your answer
Address *
Your answer
I.D. Number *
Your answer
Alternate Contact Person
Your answer
Alternate Contact Person Phone Number
Your answer
Description of Aid Required *
Required
Help SA is a registered NPO.
Help SA, its members and all those associated to the organisation cannot under any circumstance be held liable in any form for the medical equipment supplied to any person/s for their own use. All equipment supplied should be consulted with a medical practitioner before use. The person/s using the equipment shall be held accountable for any damages that arises through negligence. All oxygen concentrators/tanks for usage should be accompanied with a medical practitioner's consent letter and should be renewed every three months from initiation. Help SA waives all claims against any outcome from the usage/possession of equipment. Help SA does not act as a medical advisor but merely provide medical equipment for personal use only. All equipment remains the property of Help SA. The person responsible for the equipment is liable to recompansate for any damage/loss of the equipment.

By selecting the checkbox below, you are effectively providing your signature. *
Required
Get in touch
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service