Date:___/____/_________

From: ______________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Patient ID Proof Type : DL/AADHAAR/ VOTER ID/PAN (Select One)

ID no: ______________________________________

To,
Lions District 317F Service Foundation
Lions Clubs International Dist 317F
Vijaya bank building, Behind CBI, 5th Main Road,
RT Nagar,Bangalore - 560 032

Kind Attn: Dr. Simha Shastry, mjf . Region Chairperson, Region V , Dist .317F.

Sub: Rental of Oxygen concentrator

Dear Sir,

We have a COVID Patient Name :__________________________ ___________Age:___________

BU Number :_____________________ SRF ID:____________________________ who requires
oxygen support as his/her SPO2 level is :__________________ .

Request you to kindly provide us 5 LPM Oxygen Concentrator with accessories on rental basis for a
period of 1 week. We also understand and indemnify Lions Clubs International District 317F and its
cabinet officers against any claims whatsoever due to any reason/ results arising out of using the
Oxygen Concentrator provided on rental.

We also understand and note that Lions Clubs International and its authorised representatives shall
not be held responsible for any mishap/tragedy or morbidity arising out of the usage of the Oxygen
Concentrator.

The Oxygen Concentrator shall be used at the above mentioned address only at all times and shall
not be moved to any other location without seeking written permission from the authorised Cabinet
Officers of Lions Clubs International, Dist. 317F.

We also shall be responsible for returning the Oxygen Concentrator with all accessories in good
working condition on ______________ (Date) failing which we shall make good the market price of
the Oxygen Concentrator.

On behalf of the patient,

Signature: ___________________________________________
Name:______________________________________________
Relationship with Patient: ______________________________
Contact number:________________________________________
Address: _______________________________________________
______________________________________________________
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