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1300 652 382
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Who is completing this form?
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First Name
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Last Name
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Phone
*
Email
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Referrer
Organisation
Client (Participant) Information
Name
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Surname
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Phone
*
Email
*
Address
*
Preferred contact method
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Approximate height
Approximate weight
Primary diagnosis/condition
Trial size width (Inch)
Trial size width (Inch)
10
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14
16
18
20
22
24
26
Trial size depth (Inch)
Trial size depth (Inch)
10
12
14
16
18
20
Postural support needs?
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Pressure injury concerns?
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Funding source
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NDIS/Case number
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Power Assist
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Seating & Positioning
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Accessories
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Air Cushion
All-Wheel Drive
Back Support
Bariatric Commodes
Basic Power Chairs
Belts & Harnesses
Bikes & Trikes
Canopies & Bags
Car Safety
Custom Padding
Custom Seating
Deep Lateral Back Support
Foam Cushions
Front Mounted
Front Wheel Drive
Gel Cushions
Head Support
Hybrid Cushion
Hygiene
Indoor Alternative Seating
Indoor Sitting
Made To Order
Mid Lateral Back Support
Mid Wheel Drive
Mobility Scooters
Non-Tilting Commodes
Postural Back Support
Powered Wheels
Rear Mounted
Rear Wheel Drive
Seat Cushions
Sitting & Positioning
Sleep Systems
Standing
Strollers
Therafin
Tilting Commodes
Tub Sliders & Seat
Walkers & Gait Trainers
Wheelchair Accessories
Wheelchair Seating
Youth Chairs
Folding Wheelchair
Paediatric Wheelchairs
Rigid Wheelchair
Sleep Systems
Tilt Wheelchair
Wheelchairs
Reason for Trial
First Equipment
Replacement Equipment
Upgrade/change in needs
Short-term use
Other
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Select a product to trial
Air Cushion
All-Wheel Drive
Back Support
Bariatric Commodes
Basic Power Chairs
Belts & Harnesses
Bikes & Trikes
Canopies & Bags
Car Safety
Custom Padding
Custom Seating
Deep Lateral Back Support
Foam Cushions
Front Mounted
Front Wheel Drive
Gel Cushions
Head Support
Hybrid Cushion
Hygiene
Indoor Alternative Seating
Indoor Sitting
Made To Order
Mid Lateral Back Support
Mid Wheel Drive
Mobility Scooters
Non-Tilting Commodes
Postural Back Support
Powered Wheels
Rear Mounted
Rear Wheel Drive
Seat Cushions
Sitting & Positioning
Sleep Systems
Standing
Strollers
Therafin
Tilting Commodes
Tub Sliders & Seat
Walkers & Gait Trainers
Wheelchair Accessories
Wheelchair Seating
Youth Chairs
Folding Wheelchair
Paediatric Wheelchairs
Rigid Wheelchair
Sleep Systems
Tilt Wheelchair
Wheelchairs
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Reason for Trial
First Wheelchair
Replacement wheelchair
Upgrade/change in needs
Short-term use
Other
Environments & Access
Main environments used
Home
School
Workplace
Indoors
Community
Rough terrain
Public transport
Other
Access limitations
Narrow doorways
Stairs
Ramps
Small lift
Tight turning spaces
Uneven ground
None known
Other
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