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Request for Equipment Hire
Referrer Details
First name
Last name
Email
*
Role
Please Select
Speech Pathologist
Occupational Therapist
Self
Parent
Support Coordinator
Plan Manager
Supplier
Other (please specify)
Please specify if 'other'
Referring therapist's mobile
Company name
Equipment Details
Equipment requested for hire
Type of case if iPad
Please Select
Tough case with kickstand & Strap
Tough case with kickstand & handle (no strap)
Tough case with kickstand without Strap
Speech case
Other (please specify below)
Keyguard required?
Yes
No
Keyguard details (for which apps? grid configuration?)
Equipment details e.g. apps requested, case type if not listed above)
Preferred voice
Please Select
Olivia (child)
Liam (child)
Lisa (adult)
Tyler (adult)
N/A
Other (please specify)
Specify voice if 'other':
Hire period (number of months)
Please Select
1
2
3
4
5
6
Other (please specify)
Hire period detail
Deliver to
Please Select
Therapist's Address
Client's Address
Other (please specify)
Delivery detail
Street address
City
State/Region
Please Select
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postal code
Client's Details
Client's first name
Client's last name
Client's date of birth
Indigenous Status
Please Select
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander
Not Known
Funding type
Please Select
NDIS
TAC
Home Care Package
ECDS
Private
Other (please specify below)
Funding type if 'other'
NDIS number
NDIS plan management
Please Select
Plan Managed
Self Managed
If plan managed, please specify plan manager company name:
NDIS funding support category for hire and delivery fee - Consumables (Core) or Assistive Technology (Capital)
*
Selecting the funding support category will ensure that the funds are claimed correctly via the participant's NDIS plan.
Please Select
Consumables (Core) funding
Assistive Technology (Capital) funding
I'm not sure
N/A
Client / Parent / Guardian / Authorised Representative Contact Details
For quote and invoicing purposes.
Quote to be sent to:
Please Select
Referring Therapist
Client
Parent
Support Coordinator
Authorised Representative (please select relationship below)
Please specify if 'other' to send quote to:
Authorised representative's name (if different from client e.g. parent's / spouse's name)
Relationship to client
Please Select
Self
Parent
Foster Parent
Wife
Husband
Partner
Son
Daughter
Sibling
Support Coordinator
Case Manager
Other (please specify)
Specify relationship if 'other':
Email address to send quote and invoice to:
Contact mobile
Any Further Details / Comments?
Detail / Comments
How did you hear about our service?
Please Select
KimTech website
I have previously hired from KimTech
Email from KimTech
ComTEC website
Another therapist / colleague who was aware of KimTech
Another person (friend / family member) who has used KimTech previously
Google search
Facebook group
ARATA List Serve
Yooralla website
Other (please specify below)
Please specify how you heard about our service (if other):
I confirm that I have obtained consent from the client or the client’s authorised representative to submit this request for equipment hire and for the collection of associated data.
*
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