Book Rental Form – Neurofeedback Rentals

Please select the rental package

4 Week Rental - $890.00
12 Week Rental - $2,000.00
52 Week Rental (First Payment) - $135.00
N.D.I.S - Privately Paid Rental - $600.00
D.V.A - Privately Paid Rental - $600.00

First and Last Name of Responsible Person

When would you to receive the system?

Phone

Email

Delivery Address

Drivers Licence - Front

Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera

Drivers Licence - Rear

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Please list the people you want pre-entered to use the system

*You can add other people at anytime

you Phone take

Please list any alternate addresses you will take the system (for our insurance)

Please upload a copy of your N.D.I.S Participant Agreement

Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera

You can redact out the budget, we are just wanting to see the name of the participant and the dates

Please upload a copy of your D.V.A Gold Card

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ANNUAL SPECIAL CONDITION

I agree to the special terms for the annual commitment listed below

This agreement is for a very reduced weekly price dependant on a 52 week commitment of $135 paid per week for the week coming up - totalling $7,020. If you decide to pull out early you will need to bring the total payments up to the standard level of $900 for the first 4 weeks, a total of $2000 for the first 12 weeks and $187.5 for each week after 12 weeks. By signing this agreement, you are accepting this condition.

Read Terms & Conditions

Read Care Instructions and Consent Agreement

Agreement to Terms & Conditions, Care Instructions and Consent Agreement

I agree to the Terms & Conditions, Care Instructions and Consent Agreement Above

Signature

Clear Signature

Total

$0.00

Select Payment Method

Direct Deposit
Pay ID
Credit Card
PayPal or Apple Pay

Direct Deposit Payment

Please complete your booking form submission.

We will email you our bank account details within one business day.

Please click Book Now and your rental will be sent once payment has been received.

PayID Payment

Please transfer payment using the details below:

PayID: 42 638 666 869
PayID Name: Valor Pty Ltd

Please use your full name as the payment reference.

Please click Book Now and your rental will be sent once payment has been received.

Credit Card

Card

Name on Card