Repurchase Product Form

In this form we refer to 'client' as the person requiring mobility support.

This form is for repurchase of a product that has already been prescribed as fit for purpose.

If this product has not been prescribed, please email your enquiry to disabilities@kidsafeqld.com.au.

Alternatively, you can request a consultation by completing this form and providing detailed information.

If you have difficulties completing the form, please contact us on 07 3854 1829

As the person completing the form, what is your relationship to the 'client'? *

Has the 'client' had a consultation with us before? *

YesNoNot sure

This allows us to give you continuity of care and refer back to previous consultation notes.

Parent/Carer contact details

First Name: *

Last Name: *

Home Address: *

Email address: *

Phone Number: *

Allied Health contact details

Company: *

First name *

Last name: *

Office address: *

Email address: *

Phone: *

Funding details

NDIS Client Number *

NDIS Plan dates if applicable *

How are you funded through NDIS *

If 'other' please give more details

Send invoice/ quote to: *

Parent/CarerAllied HealthPlan ManagerAgency

Is the client a PACE participant? *

Company name: *

First name: *

Last name: *

Email address: *

Phone: *

Client information

Client's first name: *

Client's last name: *

Date of birth *

So that we can select the right products to suit the client's needs, we need to know more about their physical size.

Client's approx. overall height (cm) *

Client's approx. torso height (cm) *

Client's approx. weight (kg) *

Product Details

Please list as much information as possible about the product, including if you'd like a different size or the same size.

Product details *

Conditions of sale

1. A quote will be issued for approval before an invoice is sent for payment.

2. Payment of invoices is within 14 days.

3. Products will only be sent once payment has been received.

4. We endeavor to ship products within 2 business days after receipt of funds. Any delays due to stock availability will be communicated with relevant parties.

Product/ service satisfaction

If you or the client have any concerns regarding a service or product provided by Disability Safe Seating Solutions (a division of Kidsafe Qld) please contact Kidsafe Qld directly at 3854 1829 or email disabilities@kidsafeqld.com.au

Product warranties will apply and it is the client’s responsibility to ensure warranty terms and conditions have been met. Kidsafe Qld is not responsible for any product/s that are damaged due to misuse and the warranty is voided.

Alternatively, contact National Disability Insurance Scheme Quality and Safeguards Commission www.ndiscommission.gov.au/about/complaints

Confirmation of use

NDIS Participants: By accepting these conditions of sale you are warranting that the harness requested has been prescribed by an Allied Health Professional and all documentation for its use is in place.

Do you accept the above conditions of sale? *

IN THE SIGNATURE PANEL BELOW YOU CAN SELECT:
'DRAW SIGNATURE' to use your finger to write your signature on a mobile device (phone or tablet)
'TYPE SIGNATURE' - to use your keyboard to write your signature (phone, tablet or desktop)

Signature *

Draw signature|Type signatureClear

We will be in touch with you as soon as possible