Client Details (DES Internal Use only) ESIS ID: Phone Date of Birth Last Name First Name Preferred Name Gender M F Non-binary Email Usual Address Suburb Postcode Pension No (if req) Weight (KG) <40 >40 >90 >110 >120 >150 >170 >190 >210 Alternate Contact (if applicable) Guardian Other Preferred contact Y N Name Relationship Phone Email Prescriber Details Name Date Hospital / Agency Profession Email Fax Phone Provider No.(if req.) Equipment Request Details Delivery Contact assessor before delivery (Address if not as above / contact person / phone / special needs) Instructions (Special needs; Installation heights, location etc) Safety Instructions Nil Alerts Alerts (Precautions/alerts for DES staff only to see) (provide details) Can a Is this a Delivery Timeframe Standard Urgent substitute (additional cost) Quantity Preferred Delivery Time AM PM Any item be item offered Item no. Equipment Description Billing Information (person or agency responsible to complete) Private Hire Agency I have been made aware of the delivery charge (unless collected from DES directly) I have been made aware of the weekly private hire fees (which are billed monthly) I take responsibility for payments Name _____________________ Relationship to Client _____________ Billing Address __________________________________________Direct Phone _____________ Signature _____________________ Date _______
Client Details (DES Internal Use only) ESIS ID: Phone Date of Birth Last Name First Name Preferred Name Gender M F Non-binary Email Usual Address Suburb Postcode Pension No (if req) Weight (KG) <40 >40 >90 >110 >120 >150 >170 >190 >210 Alternate Contact (if applicable) Guardian Other Preferred contact Y N Name Relationship Phone Email Prescriber Details Name Date Hospital / Agency Profession Email Fax Phone Provider No.(if req.) Equipment Request Details Delivery (Address if not as above / contact person / phone / special needs) Contact assessor before delivery Instructions (Special needs; Installation heights, location etc) Safety Instructions (Precautions/alerts for DES staff only to see) Nil Alerts Alerts (provide details) Delivery Timeframe Standard Urgent (additional cost) Preferred Delivery Time AM PM Any Quantity Is this a item Can a substitute item be offered Item no. Equipment Description Billing Information (person or agency responsible to complete) Private Hire Agency I have been made aware of the delivery charge (unless collected from DES directly) I have been made aware of the weekly private hire fees (which are billed monthly) I take responsibility for payments Name _____________________ Relationship to Client _____________ Billing Address __________________________________________Direct Phone _____________ Signature _____________________ Date _______
Equipment%20Prescription%20Private%20Hire%20and%20External%20Agencies%20Form.docx