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)

Ship to: (required)

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

Address 2

Suburb (required)

State (required)

Postcode (required)

Equipment (if the required equipment is not listed please contact

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
Sign Name:


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