Your Name (required)

Name of organisation / therapy / school (required)

Your Email (required)

Your Phone number (required)

Name of client trialling device (required)

Your relationship to the client (required)

Shipping Address (Street address please, no PO box) (required)

Address 2

Suburb (required)

State (required)

Postcode (required)


How long would you like to trial the equipment for (required)
1 week2 weeks3 weeks

Please indicate if you require any additional accessories (your eye gaze loan device comes with a table stand or clamp-on mount):
Quha ZonoMonty 3d Eyecontrol HD QSFloorstand Variolock QPJelly Bean SwitchSpecs SwitchKeyguard (see below)

Keyguard - please specify software & number of cells:

I have read and understand the loan terms and conditions
Name & Date:


Note: If you haven’t heard from us within 2 weeks from requesting the equipment trial, please contact us on or 08 7120 6002.