Request an Equipment Trial

Complete the form below to request an equipment trial. A product specialist 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 REFERRAL FORMS pull down menu.

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*

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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Request an Equipment Trial