Equipment Loan Request

    **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)


    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

    How long would you like to trial the equipment for? (required)

    1 week2 weeks3 weeks

    Please indicate if you require any additional accessories:

    Headmouse NanoQuha ZonoJelly Bean Switch (with device only)Specs Switch (with device only)L3D MC-2QS Flex Switch

    Please indicate if you require an additional device mount: [your eye gaze loan device comes with a table mount]

    Do you need a keyguard? (required)

    If yes, please refer to the appropriate list and enter the cell description and part number below:

    Tobii I-110 Keyguard List

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

    Note: If you haven’t heard from us within 2 weeks from requesting the equipment trial, please contact us on or 08 7120 6002.  Please check junk/spam folders!