Patient Loan Application – Lung Foundation of Malaysia

Application for Loan of CPAP/BPAP/OXYGEN CONCENTRATOR/PORTABLE OXYGEN

Please complete all required fields marked with *

Patient Information

Name of Patient *

I.C. Number * Format: 000000-00-0000

Address *

Tel No. *

Email Address For confirmation email

Date *

Guardian Information (For Paediatric Patient)

Name of Father/Mother/Guardian

I.C. Number

Date

Emergency Contact Details

Name *

Tel No. *

Relationship to Patient

Witness

Name *

I.C. Number *

Date *

Terms and Conditions

The machine is on loan to the patient. It remains the property of the Foundation.
The full set machine must be returned to Lung Foundation of Malaysia when the patient does not require the use of the machine and must be in good condition upon returning.
Parents / Guardians / Patient is responsible to take good care of the machine and to pay for the cost of repairing the machine while the machine is in the user's possession.
The Lung Foundation of Malaysia reserves the right to take back the machine at any time if the rules were violated and/or the patient does not require the use of the machine.

I have read and agree to the terms and conditions *

I confirm that I have been explained the use of the machine and understand the care instructions *

Acknowledgement

Name of Patient/Father/Mother/Guardian *

Date *

Guarantor Information

Name of Guarantor *

I.C. Number *

Phone Number *

Date *