New Individual Customer Contact Form

Please fill in the form below to apply as a new customer with HLS Healthcare. Please note all fields are mandatory. For any further help or queries, please do not hesitate to contact us and we can help guide you through. This form may take a few minutes to complete.

CLIENT DETAILS

First

Last

Client Email

Confirm Email

Client Contact Number

Client Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Facility or Group Home Name

Facilty Contact Number

Facility or Group Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Funding

Plan Start Date

Plan End Date

Client's Date of Birth

Onsite Contact (If different to Client)

First

Last

Relationship to Client

Onsite Contact Email Address

Onsite Contact Phone

Onsite Impediments

Prescribing Therapist Company Name

Prescribing Therapist

First

Last

Prescribing Therapist Email

Therapist Profession

Prescribing Therapist Contact Number

Support Contact Company Name

Notes: Company Email

Support Coordinator Contact Details

First

Last

Support Email

Support Contact Phone

HLS Representative who sent you this form

Send Quote to:

Therapist
NDIS
TAC
OTHER

Quote Email Address:

Send Invoice to:

Therapist
NDIS
TAC
OTHER

Invoice Email Address:

Notes:

Form Completed By

First

Last

Completed by Email

Signature

Clear Signature

Contact Us

HLS Healthcare is proud to be an Official Sponsor for

HLS HEALTHCARE PTY LTD
VIC HEAD OFFICE
Phone: 1300 931 893
67 Henderson Road
Rowville VIC 3178

NSW OFFICE
Phone: 1300 931 893
24/7 Anella Avenue
Castle Hill NSW 2154

HLS HEALTHCARE PTY LTD
Brisbane | QLD
Phone: 1300 931 893

HLS HEALTHCARE PTY LTD
Adelaide | SA
Phone: 1300 931 893

HLS HEALTHCARE PTY LTD
Perth | WA
Phone: 1300 931 893

HLS HEALTHCARE PTY LTD
Darwin | NT
Phone: 1300 931 893

HLS HEALTHCARE PTY LTD
Hobart | TAS
Phone: 1300 931 893

HLS Healthcare are the exclusive suppliers of Guldmann Hoists and provide mobility solutions for the Aged Care, Hospital, Community, Changing Places and personal care.
Our solutions and services are available Australia wide.
#BetterWaysForLiving

This web site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Services apply.

New Individual Customer Contact Form

Contact Us

Stay up to date with HLS and Subscribe Now!