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Solace Sleep Medical Group - Trial Request Form

Your detailed responses will help us tailor our services to meet your clients’ specific needs more effectively.

APPOINTMENT

MM slash DD slash YYYY
Appointment Time (Day 1)
:
MM slash DD slash YYYY
Appointment Time (Day 2)
:

CLIENT INFORMATION

MM slash DD slash YYYY
Support Company name
Primary goal of trial
Location of a Trial
Street Address
Plan Manager Name

THERAPIST INFORMATION

Therapist Name

ADJUSTABLE BED (OPTIONS)

To ensure the safe and efficient deployment, set up & recovery of Trial Equipment, adjustable base and mattress formats will be in KING SINGLE Only.
Hi Low
Low Low
Requirements
Non-Hi Lo
Current Transfer Method
Optional Extra Support

MATTRESS (TRIAL OPTIONS)

Cool Pressure Care (18cm H)
Midnight (30cm H)
Copper Flex Hybrid (30cm H)
Copper Care – High Risk Pressure Care (25cm H)
Sol-Air Acute Risk Pressure Ulcer Prevention (25cm H)
Allure (27cm H)
Copper Flex Std (25cm H)
Himalayan (28cm H)
Pressure Mapping Required
Please allow 2 hours for trial
Duo Care (30cm H)
Current Transfer Method

RECLINER / LIFT CHAIR

The Stockman – 180kg
FEATURES
- 5 German-engineered motors
- 7cm Footrest extension
- Deluxe airline adjustable head support.
- Trendelenburg and Zero Gravity adjustment.
- Heat and Massage in-built into the seating and footrest
The Spirit & The Out Back Series
FEATURES
- Independently operate the chair’s back footrest thanks to its dual motors.
- Back reclines partially, and the legs elevate to a horizontal level.
- Supports transition to a standing position, minimizing strain on your neck, back, hips, knees, and extremities.

Please note:

If trialling 1 bed base and a couple of mattresses please allow 1 hour.
If trialling with pressure mapping, please allow 2 hours
Name
Consent

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CHECK STORES

Phone

1800 270 935

Email

[email protected]

Head Office

8 Premier Circuit, Warana, QLD 4575

Visit Our Store

69B Elvira St, Perth, WA 6157

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