Oxygen Concentrators for loan

The Perak Chest Society in partnership with Lahat Road YMCA is providing oxygen concentrators for loan.  The machines are located at 15 Clarke Street (15 Jalan Sultan Abdul Jalil).

All users are to fill in this document:

PERAK CHEST SOCIETY

178 - 180A  Jalan Pasir Puteh

31650 Ipoh, Perak

Tel: 05-2556302   Fax: 05-2432145 

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HOME OXYGEN CONCENTRATOR LOAN PROGRAMME

Person or Patient who borrows oxygen concentrator (Users): 

Name: ………………………………………………………………………………………… 

NRIC No:  ……………………………………… 

Address: ………………………………………………………………………………………

                 ………………………………………………………………………………………

Date to return oxygen concentrator: ……….... / ………….. / …………...  

Signature: ……………………………………..

Terms of Agreement between Perak Chest Society and User: 

1.        The home oxygen concentrator loan programme is available to all members of the Perak Chest Society while in stock.  It must be recommended by a doctor and a referral letter is required.

2.        Oxygen therapy must be prescribed by a doctor.  The desired oxygen concentration, flow rate, frequency and duration of oxygen use must be made known and strictly adhered to.

3.        Users are to seek immediate medical advice if their condition worsen after using supplemental oxygen or if they develop side effects from oxygen therapy or while using the oxygen concentrator unit.

 4.        The oxygen concentrator is for medium term use only and must be returned to the Perak Chest Society within one month from the date of borrowing.  

 5.        Users are to use the oxygen concentrator in a proper manner and in accordance with the operating and maintenance instructions given.

 6         Users are not to make any alterations or remove any component from the oxygen concentrator.

7.        All Users must place a deposit of RM500.00.  Upon return of the oxygen concentrator in good working condition the User will be returned RM 400.00.  A charge of RM 100.00 is levied for servicing the machine upon return.  Should the oxygen concentrator be returned damaged the cost of repair will be further deducted from the deposit.
8.        The Perak Chest Society and its Board members will not be liable to the User for any injury, damage or death arising by reason of any defect in the oxygen concentrator or as a result of using the oxygen concentrator.

Witness:

Name: ………………………………………….

Signature: ……………………………………… 

Doctor:

Name: ………………………………………….

Signature: ……………………………………… 

Today’s Date:  …………… /………………/……………..