Request an Equipment Trial

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 Rehabhire & Sales Referral Assessment Form and upload it below. The assessment form can be downloaded from the REFERRAL FORMS pull down menu or from the NDIS page on our website.

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