Equipment Hire Request Form

Person Completing Form:*

Allied Health ProfessionalClient/Self-prescribed (Low-Risk Items Only)

Low-Risk Equipment Hire

MND Queensland offers a low-risk equipment hire service to support your safety, comfort, and independence at home. Items such as shower chairs, wheelchairs, and walking aids are available to help meet your needs when you need them most.

While these items are considered low-risk, all equipment should be used with care—especially as everyone’s body, home, and support needs are different. We strongly encourage an Occupational Therapist (OT) review to ensure the equipment is safe, appropriate, and set up correctly for you.

Please note that equipment is hired and used at your own risk, as outlined in our Terms and Conditions. If you’d like help organising an OT assessment, our friendly team is happy to assist.

Client Name*

First NameLast Name

Client Phone Number*

Area CodePhone Number

Client Email

We Require either a client email address or Next of Kin Email Address

Client Diagnosis*

E.g. MND or ALS, PBP, PMA, PLS

Client DOB*

Client Communication *

How would you like to receive this equipment?*

Collect from MND Queensland (see below for address)Delivered

Collecting Equipment

Collection is by appointment only. Our team will contact you once your equipment is prepared and ready for collection. We kindly ask that you wait for this confirmation before attending the office.

Address: 1/89 Factory Road, Oxley QLD 4075

Delivery Address*

Street Address

Street Address Line 2

SuburbState / Province

Postcode

Access to Property Concerns (e.g Steep Driveway)

Delivery Contact*

Client (details as above)Other

Delivery Contact Name*

First NameLast Name

Relationship to Client

Delivery Contact Phone*

Area CodePhone Number

Delivery Contact Email

We Require either a client email address of Next of Kin Email Address

Funding Source*

NDIS FundedNDIS Eligible/Application PendingMy Aged Care FundedSelf FundedNo-cost Equipment Scheme: For individuals with MND not receiving government funding or fully using their My Aged Care packages. Please provide details on your funding status to access this no-cost charitable equipment support.Other

Support Coordinator's Name (if applicable)

First NameLast Name

Support Coordinator's Company

Support Coordinator's Email

example@example.com

Support Coordinator's Phone Number

Area CodePhone Number

NDIS Number*

This is found on any letter received from NDIS

NDIS Plan Start Date*

Date

NDIS Plan End Date*

Date

Assistive Technology (AT) Maintenance, Repair & Rental Budget Availability*

YesNo

Management Type*

Plan-managedSelf-managedNDIA Managed

Plan Manager's Name*

First NameLast Name

Plan Manager's Company

Plan Manager's Email*

example@example.com

Plan Manager's Phone Number*

Area CodePhone Number

Email for invoicing*

example@example.com

Current approved My Aged Care level (even if not currently receiving this level)*

Name of Home Care Package Organisation*

Coordinator's Name

Home Care Provider Email Address*

Home Care Provider Contact Number*

MAC Reference number

MND Queensland is a charitable organisation dedicated to ensuring that all Queenslanders impacted by MND have access to best practice care and support. This includes ensuring that vital equipment is available to those who need it. Many Queenslanders can use existing forms of funding, such as a My Aged Care - Home Care Package to pay the hire costs for MND Queensland to provide equipment. However, we are aware that some people impacted by MND do not yet have any funding or are in a position where the funding they have is inadequate to meet the cost of equipment hire, as it is needed for other important services such as in-home care. In these instances, MND Queensland will cover thecost of hire thanks to the generosity of our donors. Due to the fact that we receive no ongoing government funding and have an ethical responsibility to ensure that our donor dollars are used wisely, please complete below to confirm your eligibility for your equipment hire costs to be waived.

Eligibility will be confirmed with the client and/or their case manager/MND Advisor.

The client has a confirmed diagnosis of MND*

Yes

The reason for the client applying is:*

They are fully utilising their MY Aged Care - Home Care Package funding for other vital servicesThey have applied for NDIS and waiting for my first Plan to commence (at which time MND Queensland will commence claiming the usual weekly hire fee as per NDIS guidelines)They are waiting for approval of a My Aged Care - Home Care PackageOther

If Other - please specify*

Name*

First NameLast Name

Occupation *

Company Name*

Referring AHP Email*

example@example.com

Office Phone Number*

Area CodePhone Number

Contact Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Work Hours

Please Select Equipment Required *

	Select All Required	Please Indicate Size W x L (Inches)
Mobile Shower Commode
Mobile Shower Commode Tilt In Space
Shower Chair
Toilet Seat Raiser
Electric Bed and Foam Mattress (Single size)
Electric Bed and Foam Mattress (King single size)
Alternating Air Mattress
Repose Overlay
Hoist with Sling (Sling size and type Yoke/Pivot)
EyeGaze
Recliner (Single Motor)
Recliner (Dual Motor)
Regency Chair
4 Wheel Walker
Pressure Cushion
Manual Wheelchair
Power Wheelchair
Cough Assist Machine
Portable Suction Unit
NeuroNode + IPad
Recliner (Quad Motor)
Other (Please Detail Below)
EyeGaze Stand (by itself)
Manual Wheelchair (Tilt in Space)
Trilogy
OBI Feeder
Over Toilet Frame

Please Select - Low Risk Equipment *

	Select All Required	Please Indicate Size W x L (Inches)
Shower Chair
Over-Toilet Seat/Frame
4 Wheel Walker
Manual Wheelchair
Toilet Seat Raiser
Bedside Commode
High Backed Day Chair

Please let us know if there are special requirements (eg special attachments) *

Please indicate stand attachment for EyeGaze if selected.

By completing this request I agree:

To provide training and support in the use of this equipment to the client and any other persons who need to be familiarised with its use and operation.
I acknowledge that this equipment is from an equipment library, may not be new, and is provided to best meet the needs of the client.
The equipment is not to be modified in any way without written agreement from MND Queensland, as stated in the MND Queensland Equipment Service Loan Agreement.
Please confirm the client has consented to you sharing their information with MND Queensland and is aware that this will result in an electronic client record being created in their name on our client database for the purpose of retaining information necessary for the provision of services relevant to their care needs.

By completing this request. I the hirer:

Acknowledge that MND Queensland cannot be held liable for any injuries, loss, or damage sustained in using this equipment and that I am using it at my own risk.
Acknowledge that this equipment is from an equipment library, may not be new, and is provided to best meet my needs.
Agree to not modify the equipment in any way without written agreement from MND Queensland, as stated in MND Queensland's Equipment Hire Terms and Conditions.

Please Sign to Complete Referral*

Please note: This request will be given a registration number for future reference and a copy returned to you within 7 days indicating the availability of items requested. Your client will also receive acknowledgement in writing of this request. Our equipment team hours are Monday - Thursday 08:30am - 4:00pm Should you require a faster response, please contact our office directly on (07)3372 9004.

Equipment Hire Request Form

Client Details

Funding Details

Free Equipment Scheme

Referring Allied Health Professional

Equipment Required