• AHP Equipment Request Form

  • Client Details

    Clients WILL be registered with MND Queensland and we must have client details and signed consent to process loans, however there is no obligation to be a Member of MND Queensland.
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  • Funding Details


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  • Referring Allied Health Professional

    Please fill your details below.
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  • Equipment Required

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  • 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.
  • Clear
  • 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. Should you require a faster responce, please contact our office directly on (07)3372 9004.

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