Home Entry Permission Form

Home Entry Permission Form

Provide the details of who is allowed to enter and for what dates or times.
Date and Time of Entry

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Facility
Room Number
Facility Contact
Facility Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Resident or Person Granting Permission

First NameLast Name
Relationship to Client
Contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Apartment Number
State / ProvincePostal / Zip CodeCity
Gate or Alarm Codes
Number of items
Requested items and their location.
Special Instructions
Animal Notes
Total Cost of Service
Service fees
Base Fee
$45
Home Entry & Access Fee
$25
After Hours Fee, 6 PM to 11 PM
$20
After Hours Fee 11 PM to 8 AM
$40
Item Fee
0 to 3 = $0 and 4 to 10 = $5
Item-count breakdown
> 11 items is an additional $3 for each item. 11=$3, 12=$6, 13=$9, 14=$12, 15=$15
Starting Mileage
Ending Mileage
Total Cost of Mileage

I give permission for LB Medical Equipment Retrieval to enter the home for the purpose of retrieving medical equipment and/or personal items listed on this form. I understand that this entry is limited to retrieving the listed items only and does not include any additional services. I confirm that I am authorized to grant access to this resident and that the items I am requesting are mine or that I have legal permission to request them. I understand that LB Medical Equipment Retrieval will take before-and-after photographs of each item retrieved for documentation and verification purposes.
Initials
LB Medical Equipment Retrieval is not responsible for any items that are not recovered or are damaged before retrieval.
Initials
LB Medical Equipment Retrieval's prices are final. No refunds shall be issued if we are unable to complete the requested service for reasons beyond our control and through no fault of our own.
Initials
Signature
Print Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time

Hour Minutes

AM/PM Option
Initials
Person completing service
Name
Requested items and their location.
at pickup

Upload one or more pictures related to the requested items.
Cancelof
drop off

Upload one or more pictures related to the request.
Cancelof
Should be Empty: