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Home
About Us
What We Do
Our Team
Contact Us
Support
Patient
Fact Sheets
Alpha Thalassaemia
Beta Thalassaemia
Sickle Cell Anaemia
Family Planning
Thalassaemia
Infusion Pump Lending Services
TASCA Small Grant
Support Resources
Sickle Cell Anaemia
TASCA Small Grant
Support Resources
Family Planning
Health Professionals
Treatment Centres
Victoria
New South Wales
South Australia
Western Australia
Queensland
ACT
Tasmania
Northern Territory
TIF Publications
Health Direct
Education
School Presentations
Community Engagement
News
Awareness Days
Newsletter
Get Involved
Events
Become a Member
Become a Volunteer
Make a Donation
Give Blood
Honorary Bequest
Youth Hub
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Infusion Pump Lending Services Application
TASCA Infusion Pump Program
Please enable JavaScript in your browser to complete this form.
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Loan Agreement Form
Equipment Description
Date of Loan
*
Pump Type: MicroPump Thalapump 20 – Micrel
Pump Serial number:
*
Equipment received (please check):
Equipment received (please check):
Infusion pump
Carry bag
Shoulder holster
Instruction booklet
TASCA Member (Borrower)
Name
*
First
Last
Membership Type:
*
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
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Côte d'Ivoire
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Djibouti
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Dominican Republic
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El Salvador
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Eritrea
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Ethiopia
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Finland
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French Guiana
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French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guinea
Guinea-Bissau
Guyana
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Heard Island and McDonald Islands
Honduras
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Hungary
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India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
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Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
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Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
*
Email
*
Health Specialist
Name
*
First
Last
Hostpital/Medical Centre
*
Phone
*
Email
*
Borrower (Parent/guardian if under the age of 18)
*
First
Last
TASCA Representative
*
First
Last
TASCA INFUSION PUMP PROGRAM
*
Agree
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.
Submit