St Columcille’s Hospital Cancel Equipment Order Form

Name of Person Cancelling Equipment*

Ward*
—Please choose an option—St Josephs WardLourdes WardSt Annes WardSt Brigids WardSunflower Suite

Product
—Please choose an option—Procare Auto MattressSedens 410 Cushion

Product Rental No.*

(e.g. OFM1234) located on the pump/foot of the bed

Add another Product?
—Please choose an option—Procare Auto Air MattressSedens 410 Cushion

Second Product Rental No.*

(e.g. OFM1234) located on the pump/foot of the bed

Comment:
e.g Equipment fault or Mattress located in the sluice room

*indicates required field