Service Request Form

Thank you for contacting the Astris Lifecare Service Team.

Please enter your details below, also note that all field marked with an asterisk are mandatory.

To ensure a timely response to your request, relevant images or documents also need to be attached.

This form constitutes an NDIS Participation authorisation when the applicable field are filled in and can only be used for orders under $1500.

Kind Regards,

The Service Team

Please use the form that is most relevant to you.

Service Request - Self Managed

Participant Name *

NDIS Number (if applicable)

Date of Birth *

Participant Email

Participant Mobile Number *

Alternate Contact Number *

Participant Address *

Participant Address

City

State/Province

Zip/Postal

Country

Main Contact/Carer Name *

Main Contact/Carer Number *

Main Contact/Carer Email *

Approved Estimate Number

Describe equipment and issue *

Please upload any images if you can

Maximum upload size: 2.1MB

In order to complete this service request we will contact you for payment over the phone. A service booking fee of $143 for basic call out charge (extra charges apply for work outside of Sydney Metro) will be placed prior to the service. A further service booking fee will be charged for additional parts and labour cost as necessary.

I agree to receive communications

Service Request - Plan Manager

Participant Name *

NDIS Number *

Date of Birth *

Participant Email

Participant Mobile Number *

Alternate Contact Number *

Participant Address *

Participant Address

City

State/Province

Zip/Postal

Country

Main Contact/Carer Name *

Main Contact/Carer Number *

Main Contact/Carer Email *

Approved Estimate Number

Plan Manager Company Name *

Plan Manager Contact Name *

Plan Manager Phone Number *

Plan Manager Email *

Describe equipment and issue *

Please upload any images if you can

Maximum upload size: 2.1MB

Astris Lifecare will contact the Plan Manager to check availability of funding. Work will not proceed until sufficient funding has been confirmed in writing.

I agree to receive communications

Service Request - Agency Managed

Participant Name *

NDIS Number *

Date of Birth *

Participant Email

Participant Mobile Number *

Alternate Contact Number *

Participant Address *

Participant Address

City

State/Province

Zip/Postal

Country

Main Contact/Carer Name *

Main Contact/Carer Number *

Main Contact/Carer Email *

Approved Estimate Number

Category With Funds Available *

Describe equipment and issue *

Please upload any images if you can

Maximum upload size: 2.1MB

A service booking fee of $143 for basic call out charge (extra charges apply for work outside of Sydney Metro) will be placed prior to the service. A further service booking fee will be charged for additional parts and labour cost as necessary.

I agree to receive communications