Hire Request Form "*" indicates required fields Hiree Contact DetailsI am a* Equipment User Parent/Carer Therapist Support Coordinator Other Name* First Last Company/Organisation Name Phone*Email* Enter Email Confirm Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code NDIS/Funding Management Agency Plan Self-Managed Alternate Funding Body (Please Specify) Plan Manager* Alternate Funding Body* DOB MM slash DD slash YYYY NDIS # CONFIRMATION: Who will be using this equipment?* Myself Someone else Facility Hire Please confirm the Equipment User’s DetailsName* First Last Phone*Email* Enter Email Confirm Email NDIS/Funding Management Agency Plan Self-Managed Alternate Funding Body (Please Specify) Plan Manager* Alternate Funding Body* DOB MM slash DD slash YYYY NDIS # Add Additional Contact Details Equipment User Parent/Carer Therapist Support Coordinator Other Name First Last Company/Organisation Name PhoneEmail Enter Email Confirm Email NDIS/Funding Management Agency Plan Self-Managed Alternate Funding Body (Please Specify) Plan Manager* Alternate Funding Body* DOB MM slash DD slash YYYY NDIS # Hire DetailsRequired Hire Period (Weeks)* Preferred Minimum Hire Period = 4 weeks (Other to be negotiated)Required Start Date (if known) DD slash MM slash YYYY Hire Equipment Required* Powered Wheelchair Manual Wheelchair Special Needs Stroller Shower Commode/Bath Chair Alternate Indoor Seating Recreational Equipment Gait Trainer/Walker Standing Frame Mobile/Gantry Hoist Special Needs Bed Special Needs Mattress Hire Requirements/Details*Pressure Injury Confirmation*Do you/the hiree have any current or pre-existing pressure injuries? Yes (please provide detail) No Delivery/Collection Required?* Yes No Delivery/Collection Address* Same as Above Add New * Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Access ConsiderationsFile Drop files here or Select files Max. file size: 50 MB, Max. files: 6. **IMPORTANT INFORMATION FOR BED INSTALLATIONS (FOR PURCHASE, TRIAL OR HIRE)*Please note: where a bed is to be installed by Urgoform, any existing beds and/or furniture must be removed from the space prior to the delivery. Urgoform accepts no responsibility for the removal/relocation of exisitng furniture, unless prior special arrangement has been made. Installs in locations with difficult access will be risk-assessed and completed in conjunction with an approved furniture removalist. Please check the box to acknowledge you have read and understood the above Measurements/Equipment RequirementsPowered Wheelchair Options Tilt-in-Space Seat Elevate Backrest Recline Elevating Legrests Standing Function User Controller – LEFT User Controller – RIGHT Attendant Controller Manual Wheelchair Options Tilt-in-space Elevating Legrests Self Propelled Attendant Propelled Power Assist Hanger/Backrest Dynamics Client Weight (Kg)Client Measurements – (please complete as many fields as possible)A) Hip WidthB) Seat Depth(back of pelvis to back of knee)C) Calf LengthD) Seat to Rib CageE) Seat to Shoulder BladeF) Seat to Top of ShoulderG) Trunk WidthH) Seat to AxillaI) Seat to top of Pelvis(PSIS to ITs)K) Seat to Base of SkullL) Back of the Pelvis to Seat Bones (ITs)Additional Details**All information submitted on this form is held in strict confidence as per Urgoform’s Privacy Policy