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EQUIPMENT SHOWROOM @ ILC BOOKING ENQUIRY

Please complete one booking query per child.

I consent to non-identifying information about my equipment needs to be used by Special Aussies Foundation to lobby the government to increase paediatric equipment funding. Yes No

Name of Carer:
Contact Email:
Contact Phone Number:
Name of Child:
Age of Child:
Diagnosis:
Postcode:
Preferred Days:
Please note that whilst the ILC will try and accommodate your preferred days and times, as the centre is busy, we may require you to be flexible in your availability in the interests of scheduling your appointment asap.
Child OT name:
Postcode:
OT Agency:	Other please specify
My Child's OT will be attending:	Yes No
My Child's Physio name:
Physio Agency:	Other please specify
My Child's Physio will be attending:	Yes No
Click all equipment categories you would like view/fit:	Other please specify
Click all equipment items you would like to view/fit:

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