GAME READY RENTAL FORM The Game Ready System has been prescribed for you because your practitioner believes that it will assist in your recovery. Accepting your practitioner's recommendation is your choice. Is your Game Ready Rental a: Private Rental - (Credit Card payment only - a Customer Service Member will be in touch to collect payment) Workers' Compensation - Your insurance company may or may not cover all or part of the cost of the use of this product. It is your responsibility to check with your insurance company for approval. Private Rental Patient Details (please complete) We will contact you to confirm your Game Ready rental. Please allow at least 5 business days for the commencement of the rental period. If you require the rental prior to this, please call Customer Service on 1300 473 422.* First Name: Surname: Home Address Street Address 1 Street Address 2 Suburb State (please select) State (please select) Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Postcode Phone Email Address Type of Surgery/Injury Prescribed by - Name of Doctor Is your Delivery Address different from your home address? Yes No Is your Delivery Address a business address? Yes No Delivery Details (please complete) Contact Name Street address 1 Street address 2 Suburb State (please select) State (please select) Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Postcode Delivery Details (please complete) Business Name Contact Name Street address 1 Street address 2 Suburb State (please select) State (please select) Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia Postcode Workers Compensation Rental: Follow the below process if your Game Ready rental payment is to be covered by an approved Workers Compensation claim. 1. Download 'Prescription for Game Ready' form and provide to your doctor. Download Prescription for Game Ready Form 2. Doctor then completes and signs form and sends it to your insurer. 3. Insurer approves and provides claim number. 4. Insurer sends completed form back to us: Email: email@example.com Fax: 1300 766 473 5. We will be in contact with you to organise delivery of your Game Ready rental. NAME OF EQUIPMENT RENTAL FEE Game Ready Control Unit + Single Hose + 1 Wrap $299.00 (incl. freight & GST) for 2 weeks$550.00 (incl. freight & GST) for 4 weeks WRAP OPTIONS (Select 1 wrap of your choice) SIZE (Please tick 1 wrap & size of your choice) Assembled Shoulder Wrap - Left M (fits chest sizes 33"-45") L (fits chest sizes 40"-55") Assembled Shoulder Wrap - Right M (fits chest sizes 33"-45") L (fits chest sizes 40"-55") Assembled Elbow Wrap - Straight One size fits all Assembled Elbow Wrap - Flexed One size fits all Assembled Hand and Wrist Wrap One size fits all Assembled Cooling Vest One size fits all Assembled Hip/Groin Wrap - Left One size fits all Assembled Hip/Groin Wrap - Right One size fits all Assembled Back Wrap One size (fits waist sizes 22"- 55") Assembled Knee Wrap One size (17" long, 32" circumference at top, 24" circumference at bottom) Assembled Articulated Knee Wrap One size fits all Assembled Ankle Wrap L (fits men's shoe sizes 6-11) XL (fits men's shoe sizes 12-18) Assembled Half Leg Boot Wrap L (fits men's shoe sizes 6-11 and women's shoe sizes up to 13) GAME READY CONTRAINDICATIONS Please read the following conditions. Compression Therapy (vasopneumatic compression) using Game Ready™ or any compression therapy device should not be used in patients: Who are in the acute stages of inflammatory phlebitis in the affected region. Who have any history or risk factors for deep vein thrombosis or pulmonary embolus (including prolonged bed rest) in the affected region (to be treated with this therapy). Who have significant arteriosclerosis or other vascular ischemic disease in the affected region. Who have a condition in which increased venous or lymphatic return is not desired in the affected extremity (eg, carcinoma). Who have decompensated hypertonia in the affected region. Cryotherapy using Game Ready or any cryotherapy device should not be used in patients: Who have significant vascular impairment in the affected region (eg, from prior frostbite, diabetes, arteriosclerosis or ischemia). Who have acute paroxysmal cold hemoglobinuria or cryoglobulinemia. GAME READY SYSTEM TERMS & CONDITIONS The rental fee will be debited from the nominated credit card starting on the first day of rental. Charges appear as Ausmedic Australia Pty Ltd. Rental fees will continue to be charged if Performance Health ANZ is not contacted regarding the termination of your rental, or if the Game Ready System is returned outside of the rental period. If you decide to purchase the Game Ready System within seven (7) days after the completion of your rental period, payments made will be credited against the full cost of the device. If the equipment is no longer required please notify Customer Service on 1300 473 422 seven (7) days before the rental period ends. A courier pick up time will be given to you. Product must be in its original packaging. If any equipment is damaged, lost or stolen, you are responsible for repair or replacement. Replacement cost will be charged at equipment replacement price. This is not a rent to buy contract. At the end of your agreement, provided you do not have any outstanding rental payments, you may: (1) Return the goods with no further obligation; (2) Continue to rent the goods; (3) Performance Health ANZ may allow you to make an offer to purchase the equipment. If there is a problem with the equipment, please contact Customer Service on 1300 473 422. I accept the terms & conditions of renting Game Ready and have read the instructions of using the wrap and device. I understand I will be using the device unsupervised at home.