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)
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 I-13Tobii Dynavox I-16Tobii Dynavox EyeMobile 5Tobii Dynavox TD PilotTobii Dynavox I-110Standalone accessory - select below

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]
No extra mountFloorstand

Do you need a keyguard? (required)
YesNo

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: