Agreement for use of the Breast Pump service

The Breast Pump will be provided to you free of charge in good working order. Please ensure that the Breast Pump is only used by the person named on this form, and is used with all due care and for the purpose for which it is designed and in accordance with the instruction leaflet. Please note that it is your responsibility to ensure that the Breast Pump is clean and sterile for your personal use and remains as such.

When the Breast Pump is no longer required, please email asking for return instructions. Cleft New Zealand Inc will arrange for the return at its own cost. Please ensure that included with the the Breast Pump for return, are the two bottle stands and the instruction leaflet. There is no need to return the bottles, tubing and other “single user” items.

By signing this form you confirm that you have consulted your medical advisor about whether using a Breast Pump is suitable for you and you should seek urgent medical assistance if you suffer from any adverse issues as a result of such use. Otherwise, please of course feel free to contact anyone at Cleft New Zealand Inc for support anytime.

In consideration for providing this Breast Pump to you, you release and discharge Cleft New Zealand Inc from any and all liability for any costs, damages or other losses whatsoever and howsoever caused whether in tort (including negligence), contract or otherwise arising out of or relating to the use of this Breast Pump.

Please notify us as soon as possible, should be the Breast Pump be lost, stolen, contaminated with bodily fluids or damaged in anyway.

Our Privacy Policy can be located at