Request a trial for purchase equipment

Complete the form below to request an equipment trial. A product specialist will contact you to discuss. If we are unable to schedule a trial when you have requested, we will work with you to book a mutually suitable date and time. Our product specialists are available Monday to Friday between 8.00am and 4.00pm. Please ensure you have completed a Rehab Hire & Sales Referral Assessment Form and upload it below. The form can be accessed from the FORMS pull down menu. The NDIS Referral Assessment Form can be accessed from the NDIS page on our website. Our Equipment Trial Policy can be viewed on our EQUIPMENT TRIALS page.

Your Full Name*

Your Job Title (if applicable)

Your Best Contact Number*

Your Email Address*

Your Organisation Name (if applicable) and Address

Client's Full Name*

Client's DOB*

Facility | Organisation | Residence Name (if applicable)

Client's Address including Postcode*

Client | NOK Contact Number*

Funding Body (e.g. NDIS | SWEP | TAC | WorkSafe | Private)*

Participant Number (if applicable e.g. NDIS | TAC)

Equipment to be Trialled*

Preferred Location* (e.g. Client Home | Facility | Rehabhire Showroom)

Address including Postcode*

Booking Date (Preferred)*

Booking Date (Alternate)*

Your Message

Please upload your completed Rehab Referral Assessment Form by clicking the button below.

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