First Name: *

Last Name: *

Email Address: *

Best Contact Number: *

Address where we should send the device *

Street address *Street address line 2

City *

State *

Postcode *

Country

Date of Birth *

Sex

FemaleMalePrefer not to answerOther

This information is used to help identify norms within the report to assist your health practitioner

Who Referred You

Practice/Clinic Name *

Referrer Name *

Email address to send reports

Referrer Phone Number *

If you have a follow up appointment booked with your referrer please let us know here

Attach your referral

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About Your Booking

Which service would you like to book *

Actigraphy Rental = $220.00Positional Therapy (Night Shift) Rental= $192.50Light Therapy (AYO) Rental= $192.50

Preferred Start Date *Bookings available from April 1st 2025. We will try to deliver your device as close to your chosen date as possible

Actigraphy Costs:

10 day Actigraphy Rental and Physician Report $175.00 ex GST

Delivery to your door and pre-paid return post $25.00 ex GST

Total $200.00 ex GST

Light Therapy Rental Costs:

14 day Light Therapy (AYO) Rental and Clinician Report $150.00 ex GST

Delivery to your door and pre-paid return post $25.00 ex GST

Total $175.00 ex GST

*if your clinician recommends that you purchase this device after your trial, we will provide you with a 10% discount voucher to use through our online partner.

Positional Therapy Rental Costs:

14 day Night Shift Rental and Physician Report $150.00 ex GST

Delivery to your door and pre-paid return post $25.00 ex GST

Total $175.00 ex GST

*if your clinician recommends that you purchase this device after your trial, we will provide you with a 10% discount voucher to use through our online partner

You will complete a daily diary as part of this service. Are you comfortable using an online form or would you prefer paper?

Yes- I am happy using a digital formNo- I would prefer to print a paper diary

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Comments:

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Status

NewBookedDevice Sent- On trialOverdueDevice Received- Awaiting ReportReport Sent- Completed

Booking Date

Confirmation sent

Date posted to pt

Tracking #- Outgoing

Device Serial Number

Instructions sent

Due Date

Tracking #- Return

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Report sent

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