**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)

    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):
    Headmouse NanoQuha ZonoJelly Bean Switch (with device only)Specs Switch (with device only)Keyguard (with device only, see below to specify)

    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:


     

    Note: If you haven’t heard from us within 2 weeks from requesting the equipment trial, please contact us on loans@linkassistive.com or 08 7120 6002.