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Infusion Pump Lending Services Application

TASCA Infusion Pump Program

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Loan Agreement Form

Equipment Description
Office use only
Office use only

Equipment received (please check):

Equipment received (please check):

TASCA Member (Borrower)


Health Specialist

Borrower (Parent/guardian if under the age of 18)
TASCA Representative
Terms & Conditions
In exchange for a loan of an infusion pump from TASCA, I agree that:
1. I have sought appropriate medical advice from a doctor that the use of this equipment
is required for my medical care.
2. TASCA is loaning the equipment to me on an “as is” basis and makes no
representations about the condition or usability of the equipment.
3. I will be the only user of the equipment and will be responsible for the proper use,
storage and care, as well as the proper procedures and methods for administration,
of the infusion pump in accordance with operating instructions detailed in the
instruction booklet.
4. I will be responsible for the purchase of consumables (i.e. syringes, batteries etc.).
5. I will accept all liability for, and will not hold TASCA or any of its employees or
representatives responsible for, any claims for damage, loss, injury, death, costs, or
expenses arising out of or relating to the equipment while I am borrowing it, whether
the claims are asserted by me or a third party, and whether the claims are asserted
against me and/or TASCA, or any of its employees or representatives.
6. I am responsible for the maintenance of the equipment and that I will return it
promptly, after I no longer need to use it, in the same condition that I borrowed it,
except for reasonable wear and tear.
7. The maximum length of loan is 3 months. The borrower can reapply after this period
pending availability of pumps.