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Trial Request Form
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Who is completing this form?
Who is completing this form?
*
Client
Family member
Occupational Therapist
Physiotherapist
Support coordinator
Other
Name
*
Phone
*
Email
*
Referrer
*
Organisation
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What would you like to trial?
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Select a Category
Accessories
Commodes
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Power Assist
Powerchairs
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Seating & Positioning
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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
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 Seating
Youth Chairs
Folding Wheelchair
Rigid Wheelchair
Sleep Systems
Tilt Wheelchair
Wheelchairs
Youth Wheelchair
Client (Participant) Information
Client Name
*
Date of birth
*
Month
Day
Year
Phone
*
Email
*
Address
*
Preferred contact method
*
Phone
Email
SMS
Approximate height
*
Approximate weight
*
Primary diagnosis/condition
*
Trial size width (Inch)
*
Trial size width (Inch)*
10
12
14
16
18
20
22
24
26
Trial size depth (Inch)
*
Trial size depth (Inch)*
10
12
14
16
18
20
Funding source
*
NDIS
My Aged Care
Private
Insurance
Hospital
Other
Unsure
NDIS/Case number
Pressure injury concerns?
*
Yes
No
Unsure
Postural support needs?
*
Yes
No
Unsure
Other details about the trial request
Equipment required for trial
Reason for Trial
*
First Wheelchair
Replacement wheelchair
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
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 Seating
Youth Chairs
Folding Wheelchair
Rigid Wheelchair
Sleep Systems
Tilt Wheelchair
Wheelchairs
Youth Wheelchair
This field is hidden when viewing the form
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
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 Seating
Youth Chairs
Folding Wheelchair
Rigid Wheelchair
Sleep Systems
Tilt Wheelchair
Wheelchairs
Youth Wheelchair
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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
Transport Requirements
Wheelchair must fit in/with
Car boot
Wheelchair accessible vehicle
Public transport
Taxi/rideshare
Not required
Unsure
Consent
*
I consent to being contacted regarding this trial request and understand this is not a confirmed booking.
*
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