Hire Agreement Form

Contact Details

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Full Name

Mobile Number

Second contact person

Second contact person's mobile number

Home Address & Delivery

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HOME Street Address (eg. 34B Brownfield St)

HOME Suburb / State / Postcode

Delivery address, including suburb (if different)

Delivery or Pick up -- Select -- Delivery $33 Pick up

Initial hire term (Hire can be extended for as long as required) -- Select -- 1 week and will collect 2 weeks 3 weeks 4 weeks 6 weeks 8 weeks 12 weeks (Includes free delivery & collection) Other

Preferred Delivery/Pick up Date

Pump Model

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Milk Collection Kit

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-- Select a Kit -- 21mm Medela Symphony Single kit $55 21mm Medela Symphony Dual kit $75 24mm Medela Symphony Single kit $55 24mm Medela Symphony Dual kit $75 27mm Medela Symphony Single kit $55 27mm Medela Symphony Dual kit $75 Ameda Single Hygeinikit $55 Ameda Dual Hygeinikit $75 No, I have the FULL kit already I have a disposable kit (NOT RECOMMENDED) I am unsure and would like to discuss

Additional Items

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Feeding Bottles 3x 150ml bottles, 2x Small/Slow teats, 3x bottle caps and teat cover all included. Suitable for babies 0 - 5 months $28.00 -- Select -- none 1 pack (3 bottles) 2 packs (6 bottles) 3 packs (9 bottles) Other. To be discussed

Medela Inserts - $25.00 per pack (2 x 21mm, 2 x 18mm, 2 x 15mm) -- Select -- none 1 pack (2 x 21mm, 2 x 18mm, 2 x 15mm) - $25 2 packs - $50 3 packs - $75 Other. To be discussed

Storage Bags - (50's $33/pk or 25's $22/pk) -- Select -- none 1 x Pack of 25 2 x Pack of 25 3 x Pack of 25 1 x Pack of 50 2 x Pack of 50 3 x Pack of 50 Other. To be discussed

Steriliser Bags ($28 per 5 pk) -- Select -- none 1 pack 2 packs 3 packs Other. To be discussed

Message / Promo Code

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Estimated Cost (approx)

This is an estimate only (pump hire + delivery/collection + selected accessories). Final totals will be confirmed by our team.

Terms of Hire

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For the hire of the breast pump, purchase of associated accessories and as a security deposit, do you give us authority to use your VISA or MasterCard credit/debit card and agree with Express@home's "Terms of Hire"? Click here for terms of hire

Submit Agreement Form