ILC Hire Booking Form
Thank you for providing the following information. This general information will allow our team to prepare for your hire and ensure the relevant equipment is available.Client Information
First Name*: / Last Name*:
Date of Birth*: / Age:
Residential Address
Street Address*: / Suburb*:
Post Code*:
Phone Number*: / Email*:
Postal Address
Street Address: / Suburb:
Post Code:
Contact person’s details (parents, guardian, carers)
First Name: / Last Name:
Relationship to client:
Street Address: / Suburb:
Post Code:
Phone Number: / Email:
Funding / Eligibility (CAEP, NDIS, WA NDIS etc):
Primary Diagnosis:
Other Relevant Medical History:
Therapist and Organisation contact details
Therapist’s Name: / Email:
Organisation:
Work Phone: / Mobile:
Equipment Details
Details of equipment you want to hire*:
List any additional accessories you require (e.g. which size keyguard do you require, mount?):
Delivery/ Return Details * Method for collection of the equipment (Please select one)
Pick Up: (please advise collectors name)
Courier: (please advise courier’s name)
Delivery Details for Courier (this delivery cost clients your responsibility)
Deliver to Name: / Deliver to phone:
Street Address: / Suburb:
Post Code: / Email:
Who is paying for delivery costs?
Name:
Address:
Phone Number: / Email:
Invoicing details
Person / organisation *If CAEP/ NDIS/ WA NDIS please detail organisation the funding is coming from. / Please enter one of the following:
(Family, Organisation or Other)
Name:
Address:
Phone Number: / Email:
Loss and Damage
*** Please note ILC Hire requires someone to take responsibility for loss and damage of equipment. Please contact us for a copy of our hire agreement. ***
Person or organisation who will be responsible for any loss or damage to the equipment
while on hire is:
Name:
Address:
Phone Number: / Email:
Preferred hire dates
Are you ready to hire as soon as possible or please suggest potential dates that you would like to hire the equipment?
Trial and Keep information
*Please note that if the client is in a trial site they may not eligible for the trial and keep program.*
Do you want to retain the device if the trial is successful?
Do you require support from ILC Tech? Yes No
If yes, what support do you require?
If you want to participate in the optional trial and keep program we will provide you with a written quote for purchase of the device and additional accessories so your CAEP coordinator can commit the funds in eCAEP.
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