Contact Information NDIS Service Agreement

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(Only required for NDIA Managed plans)

Email *

Record my email address with my response

Participants Name: *

NDIS Number:
*

Participants Dob:
*

YYYY

Plan start date
*

YYYY

Plan end date:
*

YYYY

Participants email address: *

Shipping address:
*

Please select suitable option from below, in which you have an allocated budget for the supports in your order to be taken from.

Assistive Equipment – Recreation

Assistive Product – Personal Care/Safety

Consumables (Core) Budget for reasonable and necessary low risk, low cost items under $500 per item

Please insert your order number here
*

Approval needed: *

The Participant/Participant Representative agrees that this Service Agreement is made for the purpose of providing goods under the Participant’s NDIS plan.

The Participant/Participant Representative will immediately notify us if the Participant’s NDIS plan is replaced by a new plan or is discontinued.

The Participant approves Kidsnest to lodge your order to the NDIS for approval and payment

Provider’s Contact Information:

Business Name: Kidsnest

Phone: 0478 819 928

Contact Name: Rebecca Klemm

Email: Info@kidsneststore.com.au

Website Address: www.kidsneststore.com.au

ABN: 20300343297

Registration ID: 4-IMFSCPJ

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