Please complete our equipment request form


Name *
Name
Preferred phone:
Preferred phone:
Postal address
Postal address
Delivery address *
Delivery address
This must be a physical address, not a PO Box.
Only required if you are an assessor requesting a trial for a client
Delivery and return dates
Delivery and return dates
Equipment delivery & return dates
Please indicate which of our equipment you would like for trial or demonstration.
It will be funded by:
Conditions of Trial *
All trial equipment is available for five working days from the time of delivery and remains the full responsibility of the requesting Assessor. All trial equipment must be shipped back in as new condition with original packaging by the return date as above. If the trial is to be extended a written trial equipment extension must be received by the due date above, outlining the reason for the extension. All Drink-Aide bottle trials are dry trial only. Trial items lost or damaged will be invoiced to the party requesting the trial. Equipment not returned will be invoiced to the party requesting the trial. If the trial is successful, to aid timely application, all paperwork should be sent to the funding authority within three working days. I have read the Conditions of Trial above.