**Please complete this form accurately as it will be part of the loan agreement.

Therapist Name (required)

Name of organisation / therapy / school (required)

Therapist's Email (required)

Therapist's Phone number (required)

Full name of client trialling device (required)

Client’s parent/carer name

Client’s parent/carer email

Client’s parent/carer phone

Ship to: (required)
ClientTherapist

Shipping Address (Street address please, no PO box) (required)

Address 2

Suburb (required)

State (required)

Postcode (required)

Equipment (if the required equipment is not listed please contact loans@linkassistive.com)

Tobii Dynavox Indi 7Tobii Dynavox I-13Tobii Dynavox I-16Tobii Dynavox EyeMobile MiniTobii Dynavox EyeMobile PlusTobii Dynavox I-110

How long would you like to trial the equipment for (required)
1 week2 weeks3 weeks

Please indicate if you require any additional accessories (your eye gaze loan device comes with a table stand or clamp-on mount):
Quha ZonoJelly Bean SwitchSpecs SwitchKeyguard (see below)

Monty 3d Eyecontrol HD QSFloorstand Variolock QPNone

Keyguard - please specify software & number of cells:

I have read and understand the loan terms and conditions
Sign Name: