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Alternative Access Kit Check out
Please complete the form to request to check out an AT kit. We will contact you within 3-5 business days.
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* Indicates required question
Are you a licensed therapist (SLP, SLPA OT, OTA, PT, PTA) working in the state of Arizona?
*
Yes
No
Name of Therapist
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Agency/Company (if applicable)
*
Your answer
Agency/Company Phone Number
*
Your answer
When would you like to check out the AT kit? Please give the STARTING date.
*
Remember, you are given up to 4 weeks to rent the equipment.
We cannot guarantee the date you request is available.
You
will also be required to do a 30 minute virtual tech assist prior to the equipment being sent out.
*
MM
/
DD
/
YYYY
Additional information you'd like to include:
Your answer
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