Solace Medical Group Trial Your responses will help us tailor our services to meet your clients’ unique needs effectively. APPOINTMENTOption Day 1 MM slash DD slash YYYY Appointment Time (Day 1) Hours : Minutes AM PM AM/PM Consult Duration (Day 1)Option Day 2 MM slash DD slash YYYY Appointment Time (Day 2) Hours : Minutes AM PM AM/PM Consult Duration (Day 2)CLIENT INFORMATIONClient Name Date of Birth MM slash DD slash YYYY NDIS or MAC Level Main ContactSupport CoPhone / MobilePrimary goal of trial Comfort Support Evaluation Pain Relief Health Benefits Temperature Regulation Location of a Trial Garage Carport Other Trial Address Street Address City State / Province / Region ZIP / Postal Code If known, brand current bed frame and size If known, current mattress Injury / Condition:WeightHeightSupporting information regarding funding: New Plan Available fundingPlan Manager Name First Last Email (Plan Manager ) THERAPIST INFORMATIONTherapist Name First Last Company PhoneEmail ADJUSTABLE BED (OPTIONS)Hi Low Transfer Master PLUS (24cm to 72cm) Transfer Master 1000 (24cm to 66cm) Home Care Hi Lo (28cm to 68cm LS/KS) Low Low Floor Line (16cm to 67cm) Requirements Massage Bluetooth Trendelenburg Voice control Crash matt Non-Hi Lo Tranquillity (32cm-37cm) Better Sleep (30cm-35cm) Client current transfer: Self Floor Hoist Ceiling Hoist Walker Wheel Chair Optional Extra Support Deck / Grab Rail Half Collapsible Full Collapsible Voice Control MATTRESS (OPTIONS)Cool Pressure Care (18cm H) Medium & Firm Midnight (30cm H) Plush Medium Firm Copper Flex Hybrid (30cm H) Medium & Firm Copper Care – High Risk Pressure Care (25cm H) Firm Edge Sol-Air Acute Risk Pressure Ulcer Prevention (25cm H) Standard Allure (27cm H) Med/Firm Copper Flex Std (25cm H) Medium Himalayan (28cm H) Medium Duo Care (30cm H) Medium & Firm Pressure Mapping – Mattress Yes No Please allow 2 hours for trialRECLINER / LIFT CHAIRThe Stockman – 180kg Standard 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 The Spirit – 180kg (60cm seat width) The Outback – 250kg (75cm seat width) 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. NotesPlease note:If trialling 1 bed base and a couple of mattresses please allow 1 hour. If trialling with pressure mapping, please allow 2 hours Δ