AT MSRP Price List. Description. HCPCS Code K0020 K0020 K0106 K0106. Part Number AP3 AP4 GAP GAPS 1386/87 FUA PT0031
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3 Client: P.O.#: AT MSRP List AP3 AP4 GAP GAPS 1386/87 FUA PT x 12 Desk Length Leatherette 4 x 16 Tapered Leatherette Standard Height Adjustable, Removable Armrest Flip-Up Armrest Left $37.50/ea. $164.00/ea. $164.00/ea. $ $ K0020 K0020 K0106 K0106 Non-Powered AMP Center Mount, Fixed, One Piece, Height Adj. Center Mount, Flip-Up, Angle Adj., One Piece, Height Adj. Center Mount, Flip-Up, Angle Adj., Two Piece, Height Adj. Side Mount, Flip-Up, Two Piece, Height Adj. Amp Support Non-Powered Legrest Options CS SP102M/SP102L Calf Strap (side mount only) Calf Strap (side mount only) BODYPOINT Aeromesh M-36 HL Heel Loops 1550 Center Mount Calf Pads SMCP Side Mount Calf Pads 827A Foot Straps Special Request: Powered or L-40 $ $ $ $351.00/ea $90.00 $90.00 $95.00 $ $ $ / Powered Legrest Options SMCP Calf Pads for Side Mount Legrest w/breathable fabric $ / / Foot Straps $68.00 K0040 K0037 K0037 K0037 K0038 K0038 E0951 E0995 HEADREST MPS Rehab HD-MF MPS Headrest LATERAL SUPPORTS MPS Comfort Company Moldable Headrest Pad Removable Multi-Axis Headrest Hardware $ L -L/RS4W4T Comfort Company Single Lateral Pad Rigid, 5 W x 4 T, Stretch-Air Cover Right Left circle xs,s,m,l $53.00/ea LT1-SA omfort Company Single Swingaway Lateral Hardware Right Left $4. /ea E08955 E1028 E1028 E0956 Rehab LT1-SA Comfort Company Single Swingaway Lateral Hardware Right Left $263/ea E1028 LT1-RGD Comfort Company Single Rigid Lateral Hardware Right Left $79.00/ea E0956 LT1-L/RS4W4T Comfort Company Single Lateral Pad Rigid, 5 W x 4 T, Stretch-Air Cover Right Left circle xs,s,m,l $53.00/ea E0956 CHEST HARNESS 1401 Loop Style Positioning Chest Strap $ E0960 SH103M Chest Strap BODYPOINT Monoflex, Rear-Pull M $ E0960 BUTTERFLY STYLE: PBH Padded Butterfly Positioning Chest Strap $ E0960 SH331L-B1 BODYPOINT Stayflex, Narrow Front-Pull L without zipper $ E0960 Pg. 3
4 CHOOSE JOYSTICK TYPE: DXREM420 Standard Joystick Module. No LCD Display and No Mono Jacks E2323 DX2 Color LCD Display w/mono Jack Ports for External Switches $ E2323 CHOOSE JOYSTICK HANDLE TYPE: Cone-Shaped - Standard BodyPoint U Shaped w/flex Shaft 3 4 $ E2323 BodyPoint Rubber Grip Handle 3 $ E2323 BodyPoint Mushroom Head Rubber Grip Handle $ E2323 $ E2323 CHOOSE JOYSTICK MOUNT: 4 Left - Adjustable Depth 4 Right- Adjustable Depth Swingaway Joystick Left 5 Right 5 $ E2323 Midline Mount Armrest Right Armrest Call for Quote E1028 JOYSTICK ACCESSORIES: JSLK Joystick Lock- Electronically locks chair from driving $ RVAL Reverse Alarm $ ALTERNATIVE DRIVE SYSTEMS: Head Array Chin Control ASL Stealth Switch-It Stealth Bibmount (Mini) Call for Quote ENVIRONMENTAL CONTROLS: iportal Control Unit - Integrates Apple Devices (iphone, ipod, ipad) into Dynamic $ iportacc iportal with Computer Mouse Accessibility. Allows user to operate any computer through sip and puff, head array, or joystick through Blue Tooth connection $1, HIP GUIDES 1509 Hip Guides $ KNEE ADDUCTORS Knee Adductors; Multi-Axis; Removable with 4.5x6 Pad $ XL ABSB EB205L-B1/HW312-KIT WC19 Push Button Style Seat Pos. Strap - 64 Push Button Style Seat Pos. Strap - 80 Airline Buckle Seat Pos. Strap BODYPOINT Evoflex Pelvic Stabilizer L And Mounting Bracket Kit $12.00 $14.00 Transit Hooks (WC 19 Compliant) with Lap Belt $ RDC V6 Seating Systems below include: Either a MPS Seat/Seat Cushion, MPS Seat Back w/ Solid Seat Pan, or Rehab Seat (see pg. 1 for a description of each style), and height adjustable armrest. (No charge if ordered w/ Power Tilt or Recline) V6 MPS Seating System or Rehab Seating w/ No Power Seating Options V6 w/ 50 Power TIS* V6 Rehab Seating System w/ 135 Integrated Shear Reduction (ISR) Power Recline* V6 MPS Seating System w/ 135 Power Recline* V6 w/ 12 Seat Elevator* lb. Capacity Reduced Drive Capability TIS Seat Elevator (Option for driving while elevated and/or tilted) *Must be ordered with upgraded elecronics SFCK or MFCK depending on number of options selected $2, $4, $4, $3, $4, $700.00/ea. K0108 E1002 E1004 E1003 E2300 K0108
5 Client: P.O.#: AT MSRP List SFCK MFCK Single Seat Function Control Kit - Function through: Joystick For operation of a single seat function through the wheelchair electronics via the drive controls $1, E2310 and/or membrane switch. TOG2 Separate Toggle $ (add for separate toggle) Multiple Seat Function Control Kit - Function through: Joystick MUST be selected if ordering two or more seat functions. This device is used to operate two or more seat functions through the wheelchair electronics via the drive controls and/or membrane switch. TOG4 Separate Toggle $2, E2311 $ (add for separate toggle) 12 x x x x x x x x x x x x x x x x V Standard MPS Seat Back 4 Extra Tall Seat Back All Vinyl Seat Back 4 Extra Tall Seat Back - All Vinyl $ $ $ CU-FN 46G M2-F BK-M BK-R BK-V Curve Cushion - Molded foam w/ medial & lateral thigh supports - size: W x L Elements Cushion - Single layer foam with quadra gel pack - size: W x L M2 Cushion - Quadra gel with pelvic, lateral & medial thigh supports - size: W x L ACTA - Back - with moldable center section and high resiliency wings circle height: Radius Back - with high resiliency foam circle height: Visco Back - with high resiliency foam circle height: $86.00 $86.00 $ $ $ $ E2601 E2601 E2607 E2613 E2611 E Removable Clear Polycarb Table (May not work w/ some options) $ E Waterproof Wheelchair Cover $ K Waterproof Joystick Cover $40.00 K Deluxe Backpack $64.00 K Armrest Bag $26.00 K Full Lighting Kit- 2 headlights, 2 Red Marker Lights w/turn Signals through Joystick $ K Luggage Rack $ K0108 PT0029 Mud Guards (Drive tires only) $ K0108 PT0035 Cane Holder (May not work w/some options) $ PT0052 Cup Holder $ PT0036 Lift Brackets- Used with 4-Point Boom Lift (NOT approved as transport tie downs) $ A02H Articulating Oxygen Holder $ PWB Power Buddy- Includes USB Charging Port and Reading Light $ $. $. $1. LGSVC $1. discounts do not apply Pg. 4
6 Client: P.O.#: AT MSRP List BAT BCSTD B Group 24 Sealed LA/AGM, Installed (Two Required) $275.00/ea. E2363 Battery Charger $ 5.00/ea. Special Notes: *Please note that the HCPCS codes indicated on this order form are our interpretation of the new codes and how we believe our products should be coded. The individual DMERC S will determine if our interpretation is appropriate and whether or not items will be accepted or denied. IIM cannot guarantee that use of the designated codes will ensure coverage or payment. Contact the insureer to confirm compliance with coding and coverage policy. *Innovation In Motion recommends all wheelchairs be fitted and programmed to the user under the guidance of the healthcare professional, knowledgeable of the particular limitations of the product. *All specifications and dimensions are approximate. *Specifications and prices are subject to change without notification. *Effective IIIQTR201. Pg. 5
The order form has (MSRP) retail prices, but your price is at least 25% less than retail price. Multiply retail by.75 or call or for a quote.
The order form has (MSRP) retail prices, but your price is at least 25% less than retail price. Multiply retail by.75 or call or email for a quote. The order form has (MSRP) retail prices, but your price
V6 & X8. Table of Contents
V6 & X8 Table of Contents Page 2. Base Page 2. Frame Color Page 3. Seating System Page 3. Reduced Drive Capability Page 4. Power Seat Options: Seat Function Control Page 4. Seat Sizes Page 4. Rehab Seat
Client Information and Specifications:
Model: Frontier V6 Hybrid Rear Wheel Drive 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 260 665 2769 Nov 17 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility
Client Information and Specifications:
Model: Extreme X8 4x4 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 260 665 2769 Jan 18 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility usa.com Bill
Model: V6 Frontier C73 Compact 201 Growth Parkway Angola, IN Phone: Jan 18. Bill To: Dealer: Contact: Address:
Model: V6 Frontier C73 Compact 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 260 665 2769 Jan 18 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility usa.com
Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.
AADL W659/W991 Quantum Q6 Edge Z with TB3 Power Positioning FOR AADL USE ONLY Pride Mobility Products Co. 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Discount:
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Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.
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Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA Sales: Phone: (866) Fax: (866)
This product is available for purchase online at www.mypride.com Account #: Date: Order No. Fax No. Phone No. PAGE 1 Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Sales: Phone:
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
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Canada Quote / Order Form Combi
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M1 - NPO. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
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C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.070118 Shipping Address * * required F r a
FUZE T50. Order Form USA. Please send your completed order form by to or by fax to
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C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
Quantum 6400Z Series Group 4 Single Power & Multiple Power Order Form 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone:
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C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.070118 Shipping Address * * required F r a
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SHIPPING INFORMATION Provider Acct #:
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C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
ORDER FORM EIPW25. with CAPTAIN'S SEAT. Print pages 1-10 to exclude pictures. Buyer State Zip
ORDER FORM Print pages 1-10 to exclude pictures. with CAPTAIN'S SEAT EIPW25 Customer Account # Date PO# Ship To Name Address City Buyer State Zip Mark For Phone Client Measurements a) Top of head to seat
STELLAR. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
MASS Script Form. 160 Kg Weight Capacity Charge. Transit Option. 136 Kg maximum weight capacity. Not available with Removable Seat Pan.
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Quantum 600 Series Group 3 Single Power & Multiple Power Order Form/ODJFS Only 300 lbs. weight capacity. Revised: December 13, 2012 Page 1 of 7
Quantum 600 Series Group 3 Single Power & Multiple Power Order Form/ODJFS Only 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA
SHIPPING INFORMATION Provider Acct #:
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Phone 0800 5 Fax 0800 5 365 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Focus CR $ 36kg weight capacity. Tilt range: -5º anterior to 50º posterior. Effective /0/0 Ship To: Address:
Quickie QM-7 Series. Live Without Limits. Available in Eight Group 3 and Group 4 Models:
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Phone: Nov-17
By Ormesa New 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List in USD Phone: 800-327-0681 Nov-17 Fax: 260-665-3047 Email: iim@mobility-usa.com Quote: P.O. www.mobility-usa.com Bill To
Quantum Rehab A Division of Pride Mobility Products Corporation
Quantum Q600 Group 3 Order Form/ODJFS Only 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)
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Traxx 3 & Atigra 2 Script Form
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MASS Script Form. Frame. Backrest. Seat Depth. Tsunami ALX K0005 Charge. Sling Position. Seat Width / Seat Depth. Seat Width.
MASS Script Form Company: Account Number: Date: Quote PO Number: RTS: Marked For: Australian Order Form Effective 05/07/2014 Ship To: Address: City: State: Zip: Phone: Email/Fax: Tsunami ALX K0005 Charge
Quantum R4000 Series Group 3 Standard Order Form 300 lbs. weight capacity
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F3 Corpus. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
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MASS Script Form. Frame. Backrest. Seat Depth
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Quantum R4000 Series Group 3 Single Power & Multiple Power Order Form / ODJSF Only 300 lbs weight capacity
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Quantum Q1121 Series Group 3 Single Power and Multiple Power Order Form 300 lbs. weight capacity
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Orderform UK / IR Valid from Version 2.1. Alex QLASS. Date:
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Specifications are subject to change without notice. 2018, Amylior Inc. (March 2018) AMYSEAT (Rev.0) Page 1 of 7
Page 1 of 7 ACCOUNT INFORMATION P.O. # or Quote: Dealer Contact Name: Email Address: Phone Number: Bill to (Name): Bill to (Location): Ship to (Name): Address: City: State: User Name or Number: User Weight:
Page 1 of 13 INTRODUCTION PATIENT INFORMATION
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Quantum 1103 Ultra Series Group 2 Static Seating 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 1103 Ultra Series Group 2 Static Seating Order Form
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Phone: Jan 17. Fax: usa.com Quote: P.O. usa.com Bill To
By Ormesa New 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 800 327 0681 Jan 17 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility usa.com Bill To Dealer:
R82 Kudu - E1233. Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features: Recline No HCPCS Code Assigned to Kudu sz 4
Account #: Purchase Order No.: Contact: R82 Kudu - E1233 Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Kudu Standard
R82 Kudu - E1233. Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features: Recline No HCPCS Code Assigned to Kudu sz 4
Account #: Purchase Order No.: Contact: R82 Kudu - E1233 Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Kudu Standard
Orderform UK / IR Valid from Version 2.1 LUCA QLASS. Date:
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C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.070118 Shipping Address * * required F r a
R82 x:panda. USD Retail Price List/ Order Form. Account #: Purchase Order No.:
Account #: Purchase Order No.: Contact: R82 x:panda USD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US Configuration
REVERSIBLE OUTER COVER: >PELVIC OBLIQUITY KIT
POSTURE SEAT MaTRx PS cushion is designed to provide superior positioning, stability and comfort. The design features an anatomically contoured shape with a unique waffled ischial relief recess, and an
R82 Stingray. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: City/State/Zip: Effective: 2/01/ Rev 7.
R82 Stingray CAD Retail Price List/ Order Form Account #: Purchase Order No.: Date: Contact: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US Configuration
Quantum 1103 Ultra Series Group 2 Single Power Order Form 200 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 1103 Ultra Series Group 2 Single Power Order Form
Q6 Edge Z Order Form with Contoured and Synergy Seating - Group 3
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Q6 Edge Z Order Form with Contoured and Synergy Seating - Group 3 Account Number:
Standard Base Price : 2,950. Standard Features
Power Wheelchair Retail Prescription Form PRONTOM41PP010716 Tel: 01656 776222 Fax: 01656 776220 JULY 2016 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
F5 Corpus VS. Dealer Information. Client Information. Client Measurements. * Indicates a Required Field. * Contact:
* Indicates a Required Field Dealer Information * Contact: Company Code: PERMNZ * Shipping Location: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends
C350 Corpus 3G. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
For the Modulite Teen seating please select the underlined options on this form and include a completed Modulite Teen Seating form
Power Wheelchair Retail Prescription Form BORAMOD111217 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2018 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
R82 Stingray - E1233
Account #: Purchase Order No.: Contact: R82 Stingray - E1233 USD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US
LIVE OUT QUICKIE QM-7 LIMITS WITH EXPERIENCE IT ALL. SEDEO Ergo Seating
EXPERIENCE IT ALL The QUICKIE QM-7 with SEDEO Ergo Seating and SpiderTrac 2.0 suspension redefines powered wheelchair technology, inside and out. Travel further, take on new challenges, and be your independent
F3 Corpus. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
q q q q q q q q q q q q q q q q q q Frame q Titanium Frame K5-CAT5-TITAN $ Includes hangers and base frame. Does not include Cross Braces.
Funder: Order Number: Date: q Quote q PO Number: Therapist: Marked For: Catalyst 5 K5-CAT5-ALI 136kg weight capacity Frame Seat Width / Seat Depth Select box corresponding to desired Seat Width and Depth
F5 Corpus VS. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
ULTRA TDX 2. Retail Order Form Max user weight 136kg (21.4 stone) Featuring
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2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) Freedom 2 Kids
Freedom 2Kids Manual Wheelchair Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Frame Options FD2K Folding Transport Optional (E1236) or (K0005) FD2K-30270 $2085 Note: Transportation
F3 Corpus. Dealer Information. Client Information. Client Measurements. * Indicates a Required Field. Prices effective: April 1, 2017.
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
SALSA M. Salsa MWD. Base Price 4,733 STANDARD SEAT: FRAME / SEAT SIZE STANDARD SEAT: CUSHION JAY CUSHIONS JAY COMFORT SEAT
Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: Country: Country: Tel: Fax: Tel: Fax: Order date: Marked for: Purchase order: SALSA M Max. user weight: 140 kg
F5 Corpus. Dealer Information. Client Information. Client Measurements. * Indicates a Required Field. Prices effective: October 01, 2018.
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
ATP MOBILITY ASSESSMENT FORM
ATP MOBILITY ASSESSMENT FORM Name: Date: Address: City: State: Zip: DOB: Weight: Height: Gender: PLACE OF SERVICE: Assisted Living Home SNF : Physician: NPI: Address: City: State: Zip: Primary Insurance:
F3 Corpus. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
WHEELCHAIR RANGE. aspire for... Comfort Posture Mobility DANISH DESIGN
WHEELCHAIR RANGE aspire for... Comfort Posture Mobility EVOKE REHAB RX ASSIST TRANSIT LITE TRANSIT www.aspirecare.com.au 300 33 0 EVOKE Lightweight & Highly Adjustable The Aspire EVOKE and EVOKE HD are
SHIPPING INFORMATION. Order
Size 3 Order Form MASS 2014 Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Pride Mobility Products Aust Pty Ltd 20-24 Apollo Drive Hallam VIC 3803 Ph: 03 8770 9600 Fax: 03 9703 2960 Date:
F5 Corpus. Dealer Information. Client Information. Client Measurements. * Indicates a Required Field. Prices effective: April 15, 2019.
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
M3 Corpus. Dealer Information. Client Information. Client Measurements. * Indicates a Required Field. Prices effective: JAN 01, 2018.
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
F5 Corpus. Dealer Information. Client Information. Client Measurements. * Indicates a Required Field. Prices effective: JAN 01, 2018.
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
R82 x:panda. USD Retail Price List/ Order Form. Account #: Purchase Order No.:
Account #: Purchase Order No.: Contact: R82 x:panda USD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US Configuration
JIVE M2 SEDEO ERGO... 5 SHROUDS... 5 CHASSIS... 5 COLOURED SHROUD ELEMENTS... 6 BACK... 37
Title - 1 - Title - 2 - Table Of Contents JIVE M2 SEDEO ERGO... 5 SHROUDS... 5 CHASSIS... 5 COLOURED SHROUD ELEMENTS... 6 BACK... 7 JAY 3 BACK... 9 SEAT... 10 DRIVE WHEEL / CASTOR WHEEL... 11 14 INCH DRIVE
Q6 Edge 2.0 Order Form with Pediatric TRU-Balance 3 Positioning - Group 3
Q6 Edge 2.0 Order Form with Pediatric TRU-Balance 3 Positioning - Group 3 Account Number: Date: Provider Name: Contact: Phone: Fax: Email: PO Number: Marked for: Ship to Address: City: State: Zip: INTRODUCTION
M3 Corpus. Dealer Information. Client Information. Client Measurements
Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified
Invacare TDX Spree Rehab Seat Power Wheelchair Price List and Order Form
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R82 Kudu - E1233. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features:
Account #: Purchase Order No.: Contact: R82 Kudu - E1233 CAD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Kudu Standard
Invacare Kite (Modulite Flex3 Seating System) Dealer Max User Weight 160Kg (25 stone)
Invacare Ltd Power Prescription Form Pencoed Technology Park Dealer Prescription Form Pencoed CF35 5AQ LPF1U2KITEFLEX011015Dealer Tel: +44 (0) 1656 776222 Fax: +44 (0) 1656 776220 July 2015 email: ordersuk@invacare.com
M3 Corpus. Dealer Information. Client Information. Client Measurements
Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified
F3 Corpus. Dealer Information. Client Information. Client Measurements
Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified
Kimba. T h e K i m b a F a m i l y o f P e d i a t r i c M o b i l i t y P r o d u c t s
Kimba T h e K i m b a F a m i l y o f P e d i a t r i c M o b i l i t y P r o d u c t s Great for Kids Easy for Moms, Dads and Caregivers! Finally, a tilt-in-space mobility system that brings it all together.
q Little Wave Flip XP - Rigid Base KF-XPRIGID $
Phone 0800 5 222 Fax 0800 275 65 Effective /06/207 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Little Wave Flip XP - Rigid Base KF-XPRIGID $ 9.8kg weight capacity. One time free
C350 Corpus VR2 Advanced
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
C350 Corpus VR2 Advanced
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
Quantum 600 XL (HD)Series Group 3 Heavy Duty Order Form 400 lbs. weight capacity
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 18643 Phone: (866)800-2002
For AADL Only AADL Cat. #W558
For AADL Only AADL Cat. #W558 Invacare 3G Storm TORQUE SP-LE Maxx Rehab Seat Power Wheelchair Suggested Canadian Price List Effective October 1, 2018 DEALER : ACCOUNT#: DEALER CONTACT: PHONE #: P.O. #:
The maximum standard user weight capacity is 300 lbs (For Invoicing, if Different then "Ship To" Location)
SAVE RESET EMAIL FORM PRINT November, 204 BILL TO: The maximum standard user weight capacity is 300 lbs (For Invoicing, if Different then "Ship To" Location) SHIP TO: Dealer Name: Dealer Name: Contact:
Adjustable Height Raised Toilet Seat Model 101 RTS Pricelist/Order Form December 2014
Adjustable Height Raised Toilet Seat Model 101 RTS Date: Name: P.O.#: Address: Name: City/State/Zip: Mark For: Phone: Account #: Fax: This Activeaid raised toilet seat is unique in its design to accommodate