Arrange a Collection

Please tell us who is filling out this form and your relationship to the client.

Requested By *

Your Email *

Relationship with Client *

If other, please specify *

Please tell us about the client.

Client Name *

NHI Number

Let us know the NHI number if you have it.

Please tell us the collection details, including the address and any specific instructions.

Collection Address *

Please select an option from the Google dropdown menu to ensure accuracy.

Organisation/Building Name

For example, Middlemore Hospital, Building 1, Level 2, Room 3

Contact Name *

Who can we contact in regards to this collection?

Contact Phone *

Item(s) To Be Collected *

Include asset numbers if known. For example, "bed #654789, mattress, manual wheelchair".

Reason for Returning Equipment *

Collection Instructions

For example, "There is a dog on the property".

Subject *

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Thank you for your enquiry