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.