Medical Device Loan Consent Form

Recipient Information

Full Name Address Contact Number

Device Information

Device Name Device ID / Serial Number Loan Period (start - end date)

Terms and Conditions

• The device remains the property of the issuing organization.
• The recipient is responsible for the care and appropriate use of the device.
• The device must be returned in good condition by the end of the loan period.
• Any loss or damage must be reported immediately.

Consent

I acknowledge receipt of the above medical device and agree to the terms and conditions of this loan. I understand the correct use and care of the device and will return it as required.