Shower Access – Hire Form

This form is to collect basic information for us to contact you to finalise your equipment needs before we give you a quote.

Thank you for planning to hire the equipment. As no one patient is the same or bathroom the same, we need to collect some basic information to ensure you rthe unit has all the necessary accessories for the patient. For each hire, we will do the install and fitting to ensure the product is optimised for the patient.

Enquirer's Details

Requesting Person Name

Patient Details

Patient's Name
Equipment Address

Occupational Therapist's

Do you have a OT?
Is it the same as enquirer?
If no, please complete the below
Name

Equipment Type to be Hired

We will send you a link to an app that will help document the bathroom needs.
MM slash DD slash YYYY

Account Details

Billing Address

Thank you for completing the form.  

We plan to contact you within 24 hours.  If sooner you can call us 1300 118 993

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