Product Hire Form Thank you for planning to hire the equipment. As no one patient is the same or bathroom the same, we need to collect some basic information to ensure the unit has all the necessary accessories for the client. For each hire, we will do the install and fitting to ensure the product is optimised for the patient.Enquirer DetailsThis field is hidden when viewing the formAre you looking to Hire or Trial? Hire Trial Requesting Person Name(Required) First Last Phone(Required)Email(Required) Client's DetailsClient's Name(Required) First Last PhoneEmail Hire Location(Required) Suburb State Post Code This field is hidden when viewing the formOccupational Therapist'sThis field is hidden when viewing the formDo you have a OT? Yes No This field is hidden when viewing the formIs it the same as enquirer? Yes No If no, please complete the belowThis field is hidden when viewing the formName First Last This field is hidden when viewing the formCompany NameThis field is hidden when viewing the formPhoneThis field is hidden when viewing the formEmail Equipment Type to be HiredWe will send you a link to an app that will help document the bathroom needs.Equipment TypeSelect OneShower Transfer SB1Bath Transfer SB2Bath Transfer with Tilt SB2TShower Roll in SB3Shower Roll in SB3TNot SureDate when the units are required MM slash DD slash YYYY How many weeks do you require the unit?This field is hidden when viewing the formAccount DetailsThis field is hidden when viewing the formClient ReferenceThis field is hidden when viewing the formBilling Address CommentsThis field is for validation purposes and should be left unchanged. Δ
