Free Demo Kit Request Form
For referring clinicians
Fill out the form below and we will send you a free
demo kit
to assess.
Once you receive the demo kit feel free to
'unbox'
and look at every aspect, to get a better understanding of your patient's experience.
Once you are ready to send it back to us, please place everything back into the box, securely close the lid and post via Australia Post using the
pre-paid postage label.
Please send the kit back to us within
7 days
of receipt so that we can share with other clinicians.
Requesting Clinician's Details
Clinician's Name
*
First Name
Last Name
Clinician Type
*
Please Select
General Practitioner
Otolaryngologist
Dentist / Orthodontist
Sleep physician
Paediatrician
Speech Pathologist / Oral Therapist
Other
If other, please comment:
Clinic Phone Number
*
Clinic email
example@example.com
Clinic Address (we will post your demo kit here)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am happy to return the Demo Kit to Healiox within 7 business days of receipt
*
YES
NO
I am happy to receive product updates and service information from Healiox
*
YES
NO
Submit
Should be Empty: