Quantum 600 XL (HD)Series Group 3 Heavy Duty Order Form 400 lbs. weight capacity

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Quantum 600 XL (HD)Series Group 3 Heavy Duty Order Form 400 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave.

1 Quantum 600 XL (HD)Series Group 3 Heavy Duty Order Form 400 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA Phone: (866) Fax: (866) Account Number: Provider Name: Contact: Phone: Fax: Date: PO#: Marked For: Ship To: Address: City: State: Zip: Discount: Terms: Freight: Taken By: SET-TO-SPEC* Please supply patient information for optimal setup prior to shipping. Client Height: Client Weight: A. Seat Width: B. Lateral Offset: C. Hip/Thigh Lateral Offset: D. Center of Gravity: Optimized based on seat dimensions E. F. Back Height from Pan: G. Lateral Height from Pan: H. Armrest Height from Pan: I. Rigging Length (whole numbers only): J. Seat to Floor Height (circle one): Seating System Low Middle Tall Contoured Seating Synergy Seat Clinician Notes: Seat to floor height are +/- 1/8 with 18 W x 18 D with Flat-Free tires (add 3/8 for pneumatic tires). Increased widths may increase lowest seat to floor heights. * While every effort will be taken to ensure items will be preset to your specifications prior to shipping, variations in options may effect final settings. Revised: January 24, 2012 Page 1 of 6

2 DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. HCPCS codes should not be considered as legal advice. All prices are MSRP. BASE MODEL EXPANDABLE CONTROLS Q-Logic EX Joystick or Enhanced Display must be ordered with a Q-Logic qquantum 600XL (HD) 3HD-C $7,021 K0851 EX Controller and Harness For Expandable Controls qquantum 600XL (HD) 3HD-SS $7,021 K0850 qquantum 600XL (HD) 3SPHD-C $7,221 K0859 COLOR Metallic Colors: Champagne Candy Apply Red Viper Blue Onyx Black Sunburst Orange Pearl Pink Pewter Silver Emerald Green Graphite Blue Sapphire Blue DRIVE WHEELS Solid Colors: Mariner Blue Cardinal Red Spring Green Solar Yellow Violet Kelly Green BASE MOUNTED FOOT PLATFORM No Base Mounted Front Platform Base Mounted Foot Platform 14 Flat-Free 4 Wide Flat Free, Knobby, Extended- $551 Traction Tires 1 (Available Thru SOF) BATTERY CHARGER 8 Amp, Off-board Charger NON-EXPANDABLE CONTROLS 75 Amp NE 75 Amp NE+ 6-Key For Up To 2 Actuators Thru Joystick $200 on 3SPHD-C Package q 100 Amp Q-Logic EX Controller $695 E2377 q Harness For Expandable Controller $350 E2313 q Q-Logic EX Joystick $700 q Q-Logic EX Joystick for Lights $700 Required For LED Light Package q Q-Logic EX Standalone Joystick $700 E2373 q Q-Logic EX Enhanced Display 2 $1, w/ Bluetooth Mouse & IR Capability (KITASMB1678) Includes: - Q-Logic EX Enhanced Display - Flexible Gooseneck - Enhanced Display Mounting Bracket PROGRAMMING q Q-Logic Handheld Programmer $545 q Q-Logic PC Programming Cable with Disk 3 $750 JOYSTICK HANDLES q Knob qmushroom Handle $71 E2323 qt-bar $107 E2323 qchin Cup $71 E qextended I-Handle $71 E2323 qsoft Ball Handle $50 E2323 qmedium Ball Handle $50 E2323 qbodypoint 3 Goal Post Handle $69 E2323 qbodypoint 4 Goal Post Handle $69 E2323 JOYSTICK MONTING BRACKETS Comes with a Quick Release, Adjustable-Height Joystick Block qfixed Inline 5 1. Increases overall base width by All mounting hardware is included in kit. See Specialty Electronics order form for additional mounting options and secondary controls. Bluetooth mouse emulator requires a run plug harness for either static or power seating. Additional fees will apply. 3. Works with Q-Logic EX and NE+ only. qswing-away $210 E1028 qinline qoffset q4 Ext. q7 Ext. qmulti-axis Fixed $100 K Use code E2323 when not used in conjunction with a chin control. 5. Not available with Q-logic EX Stand Alone Joystick. Revised: January 24, 2012 Page 2 of 6

3 CONTOURED SEATING Medium Back: qmed-back qmed-back with Solid Seat Pan 1 Seat Width: q16 q18 q16 q18 Upholstery: qblack Vinyl qbeige Vinyl qgray Fabric qgray Vinyl qbrown Fabric qbrown Vinyl High Back: qhigh-back with Headrest qhigh-back with Headrest & Solid Seat Pan 1 Seat Width 2 : q16 q18 q20 q22 q24 q16 q18 q20 q22 q24 Upholstery: qblack Vinyl qbeige Vinyl qgray Fabric qgray Vinyl qbrown Fabric Armrests: qflip-up, Removable qflip-up, Height-Adjustable, Removable $85 ea. E0973 Armpads: Left: qfull Length qdesk Length Right: qfull Length qdesk Length MANUAL RECLINER qmanual Recliner High Back with Headrest $600 E1226 qmanual Recliner High Back with Headrest $600 E1226 and Solid Seat Pan 1 Upholstery: qbeige Vinyl qgray Vinyl Seat Width: q16 q18 q20 q16 q18 q20 Armpads: Left: qfull Length qdesk Length Right: qfull Length qdesk Length SYNERGY SEATING SYSTEMS qsynergy Seating Frame $434 Seat Width: q10 q11 q12 q13 q14 q15 q16 q17 q18 q19 q20 q22 q24 Seat Width Package: q10 W-14 W q14 W-18 W q16 W-20 W q20 W-24 W q10 q11 q12 q13 q14 q15 q16 q17 q18 q19 q20 q22 q24 Seat Depth Package: q10 D-14 D q14 D-18 D q16 D-20 D q20 D-24 D Back Cane Height: q14" q15" q16" q17" q18 q19 q20 q21" q22 q23 q24 q25 Back Rest Height: q18 q19 q20 q21 q22 q23 q24 q25 SYNERGY BACK OPTIONS q Synergy Back with 1.5 Thick Back Cushion $275 Choose Lateral Extension: q10 (For Back Heights 18 ) $25 q12 (For Back Heights ) $25 q16 (For Back Heights ) $25 q Synergy Shape Back Positioning Back Various E2613/E2614 See Synergy Shape Back Order Form For Detailed Pricing, Sizes and Codes q Sling Back $98 qheavy Duty Sling Back $98 q Omit Back SYNERGY BACK CANE OPTIONS q Back Canes With Push Handles q Back Canes, No Push Handles $125 qoffset (Meso) 3 $195 q2 (1 Per Side) q4 (2 Per Side) qinset (Endo) 3 $195 q2 (1 Per Side) q4 (2 Per Side) Revised: January 24, 2012 Page 3 of 6 TRU-COMFORT SEATING Please refer to TRU-Comfort Cushion and TRU-Comfort Back order forms for detailed pricing, sizes and codes. TRU-Comfort Back Cushion q16 W q18 W q20 W $595 E2620 q22 W $695 E2621 Back Height: 4 q22 H q25 H Cover: q Allure leather-like cover qplus 4-way stretch material cover TRU-Comfort Seat Cushion 5 General Use Includes Allure leather-like cover q16 x x 18 $380 E2601 q20 x x 22 $380 E2601 q22 x x 24 $480 E2602 TRU-Comfort Plus Seat Cushion 5 Skin Protection Includes 4-way stretch material cover q16 x x 18 $380 E2603 q20 x x 22 $380 E2603 q22 x x 24 $480 E2604 ARMRESTS q Flip-back, Cane Mounted 6 q 2-post, Flip-back, Height-adjustable, $150 ea. E0973 Removable 6,7,8 q Single-post, Height-adjustable, Removable 8,9 $75 ea. E0973 qquad Release Lever qremovable, Single-post, Height Adjustable, $75 ea. E0973 Heavy Duty q8 H - 12 H q10 H-14 H q Bariatric, Removable Height, Adjustable 10 $75 ea. E0973 q8 H - 12 H q10 H-14 H q Height Adjustable Cantilever Armrests 11 $195 K0020 Angle-Adjustable: - 30 o through + 30 o 1. Includes black vinyl seat pan. Back available in listed colors. 2. Seat widths 22" or greater can not be limited recline. Seat will have pinchless hinge. 3. Dual Post Flip-back Armrests interfere with offset canes. Not available with Manual Recline or Power Recline. 4. TRU-Comfort TM Back Height is measured from the top of a 3" cushion lbs Weight Capacity. 6. Interferes with swing-away laterals 7. Height adjustable from 9"-13" in 1" increments. 8. Not available with a depth less than 14". 9. Height adjustable from 11"-17" in 1/2" increments 10. Bariatric Arms and Bariatric Armpads must be used together 11. Height adjustment from 11-17" depends on cane height. Not available with Flip Forward back canes, & Shape Back. Call for details when selecting aftermarket arm troughs or Universal Swivel Mounts.

4 ARMPADS qstraight, Full Length (2 x14 ) qstraight, Desk Length (2 x10 ) qwaterfall, Full Length (2 x14 ) 1 qwaterfall, Desk Length (2 x10 ) 1 qfalcon Gel, Full Length, (3.5 x14 ) qfull Length Gel Armpad Mounting Plate (Required) qfalcon Gel, Desk Length, (3.5 x10 ) qdesk Length Gel Armpad Mounting Plate (Required). qflat, Bariatric 2 LED LIGHTING PACKAGE Through Q-Logic EX with Lights $995 LAP BELTS q38 Lap Belt 3 q50 Lap Belt 3 q60 Lap Belt q60 Non-Retractable (Sure-Lok) q70 Lap Belt q80 Lap Belt q90 Lap Belt qpelvic Positioning Belt, 2-Point Padded Med, $ Hip Width qpelvic Positioning Belt, 2-Point Padded, Lg, $ Hip Width qpelvic Positioning Belt, 4-Point Padded, Med, $ Hip Width qpelvic Positioning Belt, 4-Point Padded, Lg, $ Hip Width LATERALS q Stealth Thoracic Laterals (pair) 4 Bracket: q125 o Swing-Away Bracket $450 E1028 (For Use with TRU-Comfort) qswing-away, Rail Mount Bracket $450 E1028 (For Use with Synergy Back) Pad: qflat Pad, 3 x 5, Leather-Like Cover $200 E0956 qflat Pad, 4 x 6, Leather-Like Cover $200 E0956 qcurved Pad, 2 x 3, 4-Way Stretch Cover $200 E0956 qcurved Pad, 3 x 5, 4-Way Stretch Cover $200 E0956 qcurved Pad, 4 x 6, 4-Way Stretch Cover $200 E0956 q Stealth Pelvic/Thigh Laterals $160 pr. $56.69 ea. $125 pr. $53.52 ea. Side Side Bracket: qremovable Bracket (ea.) $250 E1028 qremovable Bracket w/ 1 Offset (ea.) $325 E1028 qflip Down Bracket (ea.) $225 E1028 Pad: qshort Pad, 4 x 4 (ea.) $90 E0956 qmedium Pad, 4 x 8 (ea.) $90 E0956 qlong Pad, 4 x 12 (ea.) $90 E0956 Adapter: q2 Depth/Height Adapter Plate 5 $25 K0108 HEADRESTS qno Headrest Required TRU-Comfort Headrest 6 q8 W Leatherette $205 E0955 q8 W TRU-Comfort Plus $205 E0955 q10 W Leatherette $205 E0955 q10 W TRU-Comfort Plus $205 E0955 qremovable Headrest Bracket $210 E1028 Stealth qsmall (9.75 W x 3 H) $205 E0955 qlarge (11 W x 6 H) $205 E0955 qsmall Comfort Plus (10 W) $142 E0955 qlarge Comfort Plus (14 W) $142 E0955 qremovable Headrest Bracket $210 E1028 qswing-away (Flip-down) Headrest Bracket $210 E1028 Used in Addition to Removable Headrest Bracket Aftermarket Bracket qthe World s Best Removable Headrest Hardware $210 E1028 NON-POWERED LEGRESTS q70 o Swing-away Legrests 7 $162 qstraight qtapered q Extruded Footplates Extruded Extensions: q11-13 q q Extruded Footplates: q7.25 x 6 q8.5 x 6 q Angle-Adjustable Footplates 8 $150 K0040 Angle Adjustable Extensions: q11-13 q q Angle-Adjustable Footplates: q6 x 8 9 q6 x 11 9 q8 x q Multi-Axis Footplates 7 $495 K0040 Multi-Axis Extensions: q q Multi-Axis Footplates: q6 x 8 9 q6 x 11 9 q8 x qhigh Mount, Clamp-On Footrest qangle Adjustable qsmall, 4 x 7.75 $356 qlarge, 4.25 x 9.25 $356 qmulti-axis qsmall, 4 x 7.75 $456 qlarge, 4.25 x 9.25 $ Not available w/ Cane Mounted, Flip Back Armrests combined with a Synergy Back. 2. Bariatric Arms and Bariatric Armpads must be used together. 4. Not available with Manual Recliner High Back. 5. Swing-away laterals interfere with flip-up arms. 6. Height adaper plate is needed w/ Tru Comfort seat cushion. Not available on the flip down bracket. 7. TRU-Comfort TM Headrests are measured at the front of the pad. 8. Extensions measured from top of seatpan to footplate. 9. with Heel Loops. 10. Only available on seats 18 W or wider. 11. Only available on seats 20 W or wider. 12. Available only on a Synergy Seat Revised: January 24, 2012 Page 4 of 6 K0040 K0040 qheavy Duty Drop-In Legrests 7,11 $420 q Angle Adjustable Footplates 8 $150 K0040 Angle Adjustable Extension Length: q q q6 x 8 9 q6 x 11 9 q8 x 11 10

5 NON-POWERED LEGRESTS (cont). qelevating Legrests 1 $325 E0990 q Extruded Footplates Extruded Extension Length: q11-14 q14-17 Extruded Footplate Size: q7.25 x 6 q8.5 x 6 q Angle Adjustable Footplates 2 $150 K0040 Angle Adjustable Extension Length: q q q6 x 8 3 q6 x 11 3 q8 x 11 4 Calf Pad Adjustment q1 Hole q3 Hole q6 Hole HIGH MOUNT FOOT PLATFORM qhigh Mount Foot Platform 5 $450 K0108 q10-14 Ext. 1 q14-17 Ext 1 ELECTRONICS FOR POWER LEGRESTS This Option Is Available through SOF. 300lb. Weight Capacity on Power Legrests qdual Actuator Through NE+ 6-Key $2,375 E2311 POWER ELEVATING LEGRESTS This Option Is Available through SOF. 300lb. Weight Capacity on Power Legrests q70 o Articulating Swing-Away Legrests, $2,395 E Articulation Range 5,6 qquad Release Lever Calf Pads 7 : q6 x 5.35 q8 x 5.86 Angle Adjustable Extension Length 1 : q11-13 q q6 x 8 3 q6 x 11 3 q8 x 11 4 Operational Method: qindependent qcombined q70 o Articulating Drop-In Legrests 5,6 $2,395 E1010 q4 Range q6 Range Calf Pads 7 : q6 x 5.35 q8 x 5.86 Angle Adjustable Extension Length 1 : q q q6 x 8 3 q6 x 11 3 q8 x 11 4 Operational Method: qindependent qcombined FOOT RIGGING ACCESSORIES qwheel Bumpers 8 $25 qheel Loops (pair) 9 $38 E0951 qgel Neoprene Footrest Sleeve (pair) 10 $65 K0108 qelr/alr Adductor Buttons (pair) $125 K0108 qposalinc Knee Adductor for $256 K0108 Swing-Away Legrests (pair) qposalinc Rail Mounted Knee Adductor (pair) $287 K0108 qresidual Limb Support $300 E1020 qankle Huggers (pair) $134 K0108 qsmall qmedium qbariatric Calf Panel 13 q22 W (Fits 20 W-24 W) $135 New! qmultiple Actuator Through Q-Logic EX $2,375 E2311 SYNERGY CUSHIONS qno Cushion Required Please refer to Synergy order forms for detailed pricing, sizes and codes. Simplicity Cushion 11 General Use q16 x x 20 $98 E2601 q22 x x 24 $98 E2602 Solution 1 Cushion 11 Skin Protection q14 x x 18 $380 E2603 q20 x x 24 $430 E2603 q22 x x 24 $430 E2604 Solution Cushion 11 Skin Protection & Positioning q10 x x 18 $380 E2607 q20 x x 24 $430 E2607 q22 x x 24 $430 E2608 Spectrum Gel Cushion 11 Positioning q12 x x 19 $480 E2605 q20 x x 24 $530 E2605 q22 x x 24 $530 E2606 Spectrum Visco Cushion 12 Skin Protection & Positioning q10 x x 18 $480 E2607 q20 x x 24 $530 E2607 q22 x x 24 $530 E2608 Spectrum Air 11 Adjustable Skin Protection q14 x x 24 $480 E2622 q22 x x 24 $530 E2623 Spectrum Air Contour 11 Adjustable Skin Protection & Positioning q14 x x 24 $499 E2624 q22 x x 24 $549 E2625 MISCELLANEOUS POSITIONING COMPONENTS qtherafin Flip-down Knee Abductor Bracket 13 $172 E1028 Pad: qsmall qmedium qlarge $135 E0957 qstealth Foot Boxes (pair) $475 K0108 qsmall qmedium qlarge qotto Bock Arm Channels (ea.) $104 E2209 Size: qsmall qmedium qlarge qotto Bock Flat Hand Pad(ea.) $52 Size: qmedium qlarge Please see positioning components order form for additional types, sizes and details. 1. Extensions measured from top of seatpan to footplate. 2. with Heel Loops. 3. Only available on seats 18 W or wider. 4. Only available on seats 20 W or wider. 5. Available only on a Synergy Seat. 6. Power ALR's come standard with Angle Adjustable Footplates with Heel Loops and Wheel Bumpers. 7. Calf pads can be found in the front rigging accessories section of i-quantum. 8. on Power Elevating Legrests. 9. with angle adjustable and multi-axis footplates. 10. Available only with non-powered swing-away legrests lbs weight capacity lbs weight capacity. 13. Not available with Highmount Foot Platform. Revised: January 24, 2012 Page 5 of 6

6 ACCESSORIES q Rear Basket 1 $103 q Cane/Crutch Holder 1 $98 E2207 q Weather Cover, Medium, Black $158 q Cup Holder $17 q Saddle Bag $28 q Flag Holder $17 q Quantum Backpack 2 $60 q Oxygen Holder Contoured Seating 1 $103 E2208 q Oxygen Holder Synergy Seat 3 $150 E2208 q Walker Holder 3 $92 K0108 BATTERY OPTIONS qnf-22, 50-Amp Batteries qmaintainance Free AGM $255 ea. E2361 qmaintainance Free Gel Cell (Universal) $295 ea. E2361 qmaintainance Free Gel Cell (MK) $295 ea. E2361 Installation: qbatteries Installed qdo Not Install COMPACT VENT TRAY (SYNERGY SEAT ONLY) Compact Vent Tray $1,395 The addition of a compact vent tray may increase the length & weight of your power chair. Mounting Bracket: Bracket is pre-selected with TRU-Comfort Back Flush 3 Offset 4 6 Offset - Accomodates Pulmonetics LTV-style ventilators. - Max Vent Dim H x 10.5 W x 13.5 / 20 lbs. - Not Available with Shape Back or Sling Back. - Not available with rear mount acessories. - Not available with flip-down back canes. Clinician Notes: 1. Includes Mounting Hardware. Not available with Manual Recliner. 2. Includes Mounting Hardware. Tru Comfort Back requires custom O2 holder, call for details. 3. Backpack may interfere w/ other rear accessories. Not available w/ contoured seating. 4. Not Available With Cane Mounted Flip Up Arms. Revised: January 24, 2012 Page 6 of 6

Quantum R4000 Series Group 3 Standard Order Form 300 lbs. weight capacity

Quantum R4000 Series Group 3 Standard Order Form 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum R4000 Series Group 3 Order Form 300 lbs. weight capacity