Second Hand Equipment Form

Second Hand Equipment

Name

First

Last

Address

Postcode

Date of Birth

Phone

Email

Medicare #

Any assistance required eg hearing, translator eg

Yes

No

Carer First Name (if required)

Carer Last Name (if required)

Carer Organisation

Carer Phone

Project contact

Client

Carer

What is your medical condition and history?

Height

Weight

What are your current living arrangements eg live alone, care home etc

What equipment are you interested in?

How did you hear about our services?

Word of mouth

Social Media

At an event

Previous client

Website

Other

Any other comments

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