Think Mobility Trial Request Form
TRIAL LOAN TERMS & CONDITIONS

1. The Health Professional agrees to either collect and return the equipment from Think Mobility or request Think Mobility to arrange delivery and/or collection of equipment.
2. Think Mobility delivery and collection fee may apply.
3. The Health Professional will hold all responsibility and liability for the demonstration and trialling of the equipment.
4. Think Mobility shall not be liable for any claims made in respect to bodily injury or damages to property caused using the equipment.
a. Health Professional shall do a risk assessment and request Think Mobility assistance to ensure the patient's safety during the trial.
b. If Health Professional does not request assistance from Think Mobility prior to the trial,Think Mobility shall not be liable for any claims made in respect to bodily injury or damages to property caused using the equipment.
5. The equipment remains the property of Think Mobility.
6. Think Mobility shall have the right to access equipment during the trial period.
7. If any defect, malfunction, or any factor threatening damage of the equipment be identified, it is the Health Professional’s responsibility to notify Think Mobility immediately.
8. The Health Professional shall exercise reasonable care of the equipment, maintain it in its original (new) condition.
9. The equipment is to be used for a dry trial only (E.g. Showering equipment is to be used without the application of water).
10. The equipment is not to be trialled with a person with an infectious condition.
11. The equipment trialled with a person that is incontinent must use the appropriate protection.
12. No modifications or alterations are to be made to the equipment.
13. If any the above conditions are breached the Health Professional will be responsible for the cost or replacement.

NOTICE: Health Professionals are required to use the DVA Direct Order Form (DOF) for approved equipment. For non-approved DVA equipment trial, please contact a Think Mobility office for further instructions.

Items Required For
Trial Location
Think Mobility Office Location
Prescriber's name
Your answer
Prescriber's email address
Your answer
Organisation (If required)
Your answer
Prescriber's Contact Phone
Your answer
Client
Your answer
Trial Address
Your answer
Equipment Required
Your answer
Trial Date
MM
/
DD
/
YYYY
Trial Time
Time
:
Notes
Your answer
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