Vitrectomy Face Down Recovery Equipment

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OakWorks Leasing Rental Reservation

Please complete the following Information

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip code:

Phone:

Email:

Surgery Date:

Affected Eye:

Right Left Both

Contact Name (if other than patient):

Packages starting at $140 weekly and $14 daily

(daily fees are only available after the first contract week)

OakWorks Leasing™ Inc. recognizes that some patients may have to experience Facedown Recovery more than once. That's why we offer a 10% discount to our previous customers.

Please select the equipment and accessories you wish to reserve:

Maximum Comfort Package

1st Week...........................$225
Each additional week..........$130
Daily.................................$19

Included In The Maximum Comfort Package:

Premier Sleep System
Premier Seated Support
Premier Table Top Face Support
3-Pad Face Cushion (3)
Crescent Face Cushion (3)
Flannel face Cushion Covers
Sternum Pad (2)
Adjustable Mirror
Instructional DVD/Video

Essential Package

1st Week.....................$165
Each additional week....$125
Daily...........................$18

Included In The Essential Package:

Premier Sleep System
Premier Seated Support
3-Pad Face Cushion (2)
Crescent Face Cushion (2)
Flannel face Cushion Covers
Sternum Pad (1)
Adjustable Mirror
Instructional DVD/Video

Economy Package

1st Week........................$140
Each additional week.......$95
Daily..............................$14

Included In The Economy Package:

Premier Sleep System
Premier Table Top Face Support
3-Pad Face Cushion (2)
Crescent Face Cushion (2)
Flannel face Cushion Covers
Sternum Pad (1)
Instructional DVD/Video

Accessories

	OAKWORKS^® Adjustable Vitrectomy Mirror 1st week........................$15 each additional week.......$10 daily...............................$2
	Travel Block 1st week........................$15 each additional week.......$10 daily...............................$2
	Butterfly Cushion 1st week........................$15 each additional week.......$10 daily...............................$2
	Table Top Face Support Carry Case 1st week........................$5 each additional week.......$5 daily...............................n/a
	Seated Support Support Carry Case 1st week........................$5 each additional week.......$5 daily...............................n/a
	Sleep System Carry Case 1st week........................$5 each additional week.......$5 daily...............................n/a
	Additional Flannel Covers $6 each - purchase only
	Fleece Face Rest Cover $11 each - purchase only

Additional Questions/Comments:

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After completing this form and clicking the submit button, one of our Personal Care Consultants will contact you regarding pricing, shipping and answer any questions you may have. You are under no obligation to reserve equipment.