Request an Appointment

Complete the form below to request an appointment. Please choose a time during business hours if you require the presence of a product specialist. A member of our team will contact you to discuss and to confirm your requested date and time. Please ensure you have completed and attached a Rehab Referral Assessment Form. The form can be downloaded from the FORMS pull down menu or from our NDIS page.

Business Hours

Monday to Friday: 8.30am – 5.00pm | Saturday and Sunday: Closed | Public Holidays: Closed

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*

Do you require a product specialist?*

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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Request an Appointment