For AADL Only AADL Cat. #W558
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1 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. #: DATE: ADDRESS: : _ To Ensure system is accurately configured, please fill in all required measurements Client Height: Client Weight (lbs.): A. Seat to Shoulder: B. Trunk Depth: C. Chest Width: D. Knee to Back: E. Seat to Top of Head: F. Elbow to Hand G. Seat to Elbow H. Hip Width I. Knee to Heel Cushion Thickness: BASE CHAIR TYPE Torque SP comes standard with 300 lb. user weight capacity, 6.4 mph maximum speed, performance 4-pole motor package, SPJ+ joystick, MK690ACC Controller and Rubber Element rear wheel suspension. 3G STORM TORQUE SP-LE - MAXX ADJUSTABLE REHAB SEAT MODEL (NOT AVAILABLE TO ORDER THROUGH INVACARE PRO) 3GTQSPLE TorqueSP-LE with MK6iTM Electronics and MAXX Adjustable Rehab Seat $7,500 TRANSPORT TIE DOWN otrbkts Wheelchair Transport Brackets No Charge Not available with shock forks for 8" casters. USER WEIGHT LIMITS U300 User Weight <300 Lbs. Standard FRAME TYPE osfs Short Base No Charge Standard with seat depths 12" - 18". Not available on seat depths of 1922D (19 to 22 seat depth range). Not available with shock forks for 8" casters. olfs Long Base $432 Standard with seat depths 19"-22". Not available on seat depths of 1218D (12 to 18 seat depth range). ADJUSTABLE SEAT WIDTH RANGE ospecial 1115W 11" to 15" Seat Width Range No Charge Must select 11"-15" Depth Range (special) when ordering the 11"-15" Seat Width Range " widths increase the STF height by 1.5". o1620w 16" to 20" Seat Width Range No Charge o1922w 19" to 22" Seat Width Range $460 ospecial 2324W 23" to 24" Seat Width Range $460 SEAT WIDTH For Seat Widths of 11"-15": Junior seat widths/depths require a straight rear upright and a user weight limit of 150 lbs " widths increase the STF height by 1.5". ospecial W11 - Seat Width 11" lbs. capacity. Paediatric dual arm posts recommended. No Charge ospecial W12 - Seat Width 12" lbs. capacity. Paediatric dual arm posts recommended. No Charge ospecial W13 - Seat Width 13'' lbs. capacity. Paediatric dual arm posts recommended. No Charge ospecial W14 - Seat Width 14'' lbs. capacity. Paediatric dual arm posts recommended. No Charge ospecial W15 - Seat Width 15" lbs. capacity. Paediatric dual arm posts recommended. No Charge ow16 Seat Width 16" No Charge ow17 Seat Width 17" No Charge ow18 Seat Width 18" No Charge ow19 Seat Width 19" No Charge ow20 Seat Width 20" No Charge ow21 Seat Width 21" No Charge ow22 Seat Width 22" No Charge ospecial W23 - Seat Width 23" No Charge The 23" & 24" seat widths are not available with low seat-to-floor. ospecial W24 - Seat Width 24" No Charge The 23" & 24" seat widths are not available with low seat-to-floor. DRIVE TYPE Note: For G-Trac Module, go to Controller area under MK6i Selection PERF Performance 4-Pole Motor Standard SEAT SELECTION ADJASBA-LE Maxx Adjustable Rehab Seat $1,200 For the most current pricing information visit Page 1 / 7
2 ADJUSTABLE SEAT DEPTH RANGE ospecial 1115D - 11" to 15" Seat Depth Range No Charge Must select 12"-15" Depth Range when ordering the 12"-15" Seat Width Range. o1621d 16" to 21" Seat Depth Range No Charge o1922d 19" to 22" Seat Depth Range $381 ADJUSTABLE SEAT DEPTH SETTING For Seat Depths of 11"-15": Jr. Seat widths/depths require a straight rear upright and a user weight limit of 150 lbs. ospecial D11 - Seat Depth 11"- 150 lbs. capacity. Paediatric dual arm posts recommended. No Charge ospecial D12 - Seat Depth 12''- 150 lbs. capacity. Paediatric dual arm posts recommended. No Charge ospecial D13 - Seat Depth 13''- 150 lbs. capacity. Paediatric dual arm posts recommended. No Charge ospecial D14 - Seat Depth 14''- 150 lbs. capacity. Paediatric dual arm posts recommended. No Charge ospecial D15 - Seat Depth 15''- 150 lbs. capacity. Paediatric dual arm posts recommended. No Charge od16 Seat Depth 16'' No Charge od17 Seat Depth 17'' No Charge od18 Seat Depth 18'' No Charge od19 Seat Depth 19'' No Charge od20 Seat Depth 20'' No Charge od21 Seat Depth 21'' No Charge od22 Seat Depth 22'' No Charge ADJASBA-LE SEAT TO FLOOR HEIGHT ospecial Seat-to-Floor Special Low (16.75" at 0 ) $250 This seat height requires an 18" wide or greater seat width. olow Seat-to-Floor Low (17.25" at 0 ) No Charge omed Seat-to-Floor Medium (18.25" at 0 ) No Charge otall Seat-to-Floor Tall (19.25" at 0 ) No Charge BACK SELECTION ADJASBA-LE BACK TYPE osect Sectional Rear Uprights No Charge ospecial SRUP - Straight Rear Uprights No Charge ADJASBA-LE BACK HEIGHT ospecial BH12 - Back Height 12'' No Charge ospecial BH13 - Back Height 13'' No Charge ospecial BH14 - Back Height 14'' No Charge ospecial BH15 - Back Height 15'' No Charge obh16 Back Height 16'' No Charge obh17 Back Height 17'' No Charge obh18 Back Height 18'' No Charge obh19 Back Height 19'' No Charge obh20 Back Height 20'' No Charge obh21 Back Height 21'' No Charge obh22 Back Height 22'' No Charge ospecial BH23 - Back Height 23'' No Charge ospecial BH24 - Back Height 24'' No Charge ADJASBA-LE BACK ANGLE DEGREE Adjustment Range with SECT back cane is 86 o -126 o o90ba 90 Degree Standard o95ba 95 Degree $71 BACK ACCESSORIES ol8601 Omit Back Upholstery Less Net ($20) ARM SELECTION ARM TYPE RIGHT o29fr Desk Length Dual Post Adjustable Height Right No Charge o19fr Full Length Dual Post Adjustable Height Right No Charge ospecial Paediatric Dual Post Armrest Adjustable Height Right - Specify seat to top of arm No Charge ARM TYPE LEFT o Short 6"-9.5" o Med. 9"-12" o Lrg. 12"-15" o19fl Full Length Dual Post Adjustable Height Left No Charge o29fl Desk Length Dual Post Adjustable Height Left No Charge ospecial Paediatric Dual Post Armrest Adjustable Height Left - Specify seat to top of arm No Charge o Short 6"-9.5" o Med. 9"-12" o Lrg. 12"-15" For the most current pricing information visit Page 2 / 7
3 CANTILEVER MIXED ARM TYPE (EACH) - Mounted in Ultra Rail oclvfr Full Length Arm Right $244 oclvdr Desk Length Arm Right $244 oclvfl Full Length Arm Left $244 oclvdl Desk Length Arm Left $244 ARMPAD OPTIONS WF Waterfall Armpads Standard MK6i SELECTION CONTROLLER ospecial MK690ACC - 90 Amp Controller with Actuator Control Standard ogtrac G-Trac Module $988 G-Trac provides Improved Tracking Capabilities and Enhanced Traction. Only available on 4-pole motors. Not available with SPJ+ joysticks. STANDARD DRIVER CONTROL ospecial SPJAP - SPJ PLUS with Mono Port for Actuator Switch Standard ospecial SPJAPM - SPJ PLUS with Mode Switch for Joystick Actuator Operation $530 MULTIPLE DRIVE CONTROL OPTIONS opwh Harness required for Expandable Electronics No Charge Harness is required to interface joystick or MK6i display with expandable controllers. Option is located under Electronics Accessories in configurator. ocmpjm6u MPJ+ Multiple Drive Joystick with Colour Display $875 oaslrdym6 MK6 Display Only (No Driver Control) $242 Display only, no driver control. Allows choice from order form. ALTERNATIVE PROPORTIONAL CONTROL SYSTEM o1558mm6 Compact Joystick with Display $1,097 ALTERNATIVE DIGITAL CONTROL SYSTEMS Must also use either a Multiple Drive Joystick or MK6 Display. osnpm6 Sip-N-Puff $2,135 SIP N PUFF KIT opkg32666 Therapin Sip-N-Puff Breath Tube Kit $440 ADDITIONAL CONTROL CHOICES o1558m6 Compact Joystick - Less Standard Mount $937 opacm6 Proportional Attendant Control with Quick Release Mount $1,024 JOYSTICK MOUNTING HARDWARE oqlam6 Quad Link Retractable Joystick Mount MPJ+ $358 QLA and QLAM6 include Stealth Adjustable Height Joystick Mount oqla Quad Link Retractable Joystick Mount SPJ+ $358 QLA and QLAM6 include Stealth Adjustable Height Joystick Mount oleft Left Hand Mounted Joystick No Charge ELECTRONIC ACCESSORIES o1813m6 MK6i Programmer with Professional Memory Card $685 o1813sd Professional Memory Card $112 oa24vps 24V MK6i Auxiliary Power Source $252 oaux12m6 Auxiliary Module For 1 & 2 $706 oaux34m6 Auxiliary Module For 3 & 4 $706 ompy Mono Port Y Cable for MPJ+ or Display $22 For use with MPJ+ or MK6i. Display to provide additional switch site. o2pb Dual Push Button $182 Option to replace Mono Port "Y" cable when requiring two switch functions of the mode switch port on expandable controller systems. Not compatible with SPJ+ Joystick options. opbmt Push Button Mounting Kit $352 For the most current pricing information visit Page 3 / 7
4 FRAME AND UPHOLSTERY COLOUR FRAME FINISH o24p Wet Black No Charge o105p Midnight Blue No Charge UPHOLSTERY COLOURS ou240 Black Nylon Upholstery Standard CASTER AND WHEEL OPTIONS CASTER OPTIONS o '' X 2 1/4'' Semi Pneumatic Casters Lt Grey Standard o '' X 2'' Pneumatic Casters No Charge CASTER SUSPENSION Not available with Short Base and/or TRBKTS. o Shock Fork For 8'' Casters $209 WHEEL OPTION o '' X 3'' Pneumatic Tires Standard o '' X 3'' Tire with Foam Filled Inserts No Charge REAR WHEEL LOCATION orws Rear Wheel Standard Standard FENDER OPTION ofdr Fender No Charge POSITIONING STRAPS SEAT POSITIONING STRAP 1515 Auto Style Buckle Seat Positioning Strap Standard CHEST POSITIONING STRAP o7321bk Hook & Loop Chest Positioning Strap $66 MISC ACCESSORIES MISCELLANEOUS ACCESSORIES o1303 Wheel Locks $93 Not available with pneumatic tires. o Upgraded Monroe Suspension Shocks $150 BATTERY SELECTION BATTERY BOXES GP24 Group 24 Battery Boxes Standard INSTALLATION OF BATTERIES Batteries will be installed by Invacare Corporation at no additional charge. Chair will be shipped complete with batteries. o24battery 24 Gel Battery (On Chair) $840 BATTERY CHARGER OPTIONS o110charger 110 Volt Battery Charger No Charge ol8900 Omit Charger No Charge For the most current pricing information visit Page 4 / 7
5 HANGER BRACKET SELECTION HANGER BRACKET TYPE oasb Centre Pivot Style Bracket No Charge FRONT RIGGING OPTIONS FRONT RIGGING CENTRE PIVOT STYLE - SOLD AS PAIR o70nhd 70 Non-Tapered Swing Away Footrest 13.5"-17" (Steel) $241 o70staper 70 Tapered Footrests 13"-17" (Aluminum) $281 Standard with 1651 composite footplates and impact guards. Not available with widths 19" - 24" and 16" deep seat or AT5543. ospecial Heavy Duty 70 Swing Away Footrests - Available with straight or flared receivers $495 o D0130-C81-A09 o D0130-C81-A12 Straight Receivers Flared outward 1 70 DEGREE FOOT BOARD ospecial D0157-BFCM - Basic Center Mount Platform 70 O - Specify Seat to Footplate Setting Below $ of ground clearance is required. Comes with Basic Footplate 12 x steel 1/8 thick with built-in heel wells. Seat to Footplate Setting: o 13" o 14" o 15" o 16" o 17" FOOTPLATE OPTIONS o1651 Flip-Up Composite Footplates No Charge o1350 Extra Large Aluminum Footplates $106 oat5543 Adjustable Angle Flip-Up Footplates $132 Not available with 70STAPER. FOOTREST/LEGREST ACCESSORIES olpt2 Longer Pivot Slide Tube For 1350 $132 oa1337 Calf Strap $63 oimpactg Impact Guards No Charge oalpt Longer Pivot And Slide Tube $132 oalpt3 Longer Pivot And Slide Tube 3" $132 oalpt4 Longer Pivot And Slide Tube 4'' $132 Not available with AT5543. Not available with Low STF Height. ohloop Heel Loops $84 RAM MOUNTS - Not Covered by AADL Subject to service part discounts only. Receive a secondary 10% discount with the purchase of one holder, one arm and one mount/suction cup. Mounts will ship separately from chairs. otaghphnc Phone Holder with Mounting Clamp $89 otaghphnb Phone Holder with 1" Ball (For use with Adjustable Arms and Clamp) $65 otaghtab7 Tablet Holder for Small Tablets (Most 7" Tablets) $89 otaghtab10 Tablet Holder for Larger Tablets (Most 10" Tablets) $119 otaghcup Cup Holder, Self Leveling, Swivel $59 otagmclamp Universal Mounting Clamp with 1" Ball $49 otagma3 Adjustable Mounting Arm (Standard Length) 3" $39 otagma6 Adjustable Mounting Arm (Long Length) 6" $49 otagmbc Mounting Arm Connector, 2.5" Long with 1" Ball Ends $33 otagmsc Accessory Mount Suction Cup with 1" Ball $29 otagmub Accessory Mount U-Bolt with 1" Ball (For Rails 0.5" to 1.25" in Diameter) $27 MATRX SEATING Approved by AADL For the most current pricing information visit Page 5 / 7
6 16.75" " Invacare Canada reserves the right to change prices and specifications without notice. HEAD OFFICE Matheson Blvd, Unit# 8, Mississauga, ON L4Z 4G4 Phone: (905) (800) (Canada) Fax: (905) (800) (Canada) For the most current pricing information visit Page 6 / 7
7 HEAD OFFICE Matheson Blvd, Unit# 8, Mississauga, ON L4Z 4G4 Phone: (905) (800) (Canada) Fax: (905) (800) (Canada) Invacare, and Yes, you can., are trademarks of Invacare Corporation. For the most current pricing information visit Page 7 / 7
Print Form Save Form Submit
Print Form Save Form Submit Clear Form Contents Invacare TDX SP-LE Maxx Rehab Seat Power Wheelchair Suggested Canadian Price List Effective June 1, 2017 DEALER : ACCOUNT#: DEALER CONTACT: PHONE #: P.O.
NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS
Print Form Save Form Submit Form Clear Form Contents Invacare TDX SP Rehab Seat Power Wheelchair Suggested Canadian Price List Effective July 25, 2017 NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS BASE CHAIR
NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS. 3 Please refer to table on page 5 for seat size combinations. BACK SELECTION
FRAME SELECTION POWER CHAIR TYPE M91-TS M91 Base w/mk6i $5,950 M71-TS M71 Base w/mk6i. $5,325 1,2 POWERED SEATING PTO-PL Power Tilt Only Plus(PTO) $2,995 Invacare Formula PTO Plus for Pronto M71 & M91
NAME PHONE NO ACCOUNT# P.O. DATE
Invacare Formula CG Elevating Seat for Storm Series Suggested Canadian Price List Effective October 21, 2015 NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS BASE CHAIR TYPE/POWER SEATING BASE 3GAR-CG Arrow for
Invacare TDX Spree Rehab Seat Power Wheelchair Price List and Order Form
Price List and Order Form TRANSACTION TYPE: Order Quote Date Account # P.O. # Company Name Phone # Address City State Zip Code Country Contact Name Comments Special Note HCPCS codes are not intended to
NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS. 4 Package includes 4 pole motors and 6.5 MPH top speed unless TRUTK CONVENTIONAL
FRAME 1 CHAIR TYPE/POWER SEATING BASE TDX5-PS TDX5 for Formula w/mk6i $8,974 TDX4-PS TDX4 for Formula w/mk6i $7,791 TDX3-PS TDX3 for Formula w/mk6i (includes Std MPJM6) $8,164 TRANSPORT TIE DOWN TRBKTS
Invacare 3G Arrow Storm Series w/truetrack Suggested Canadian Price List Effective July 13th, 2015
Invacare 3G Arrow Storm Series w/truetrack Suggested Canadian Price List Effective July 13th, 2015 NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS FRAME CHAIR TYPE 3GAR Arrow Base for Seat w/mk6i Electronics
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:
Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.
AADL W592/W991 Quantum Q6 Edge 2.0 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:
NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS. improved battery charge life. ADJUSTABLE SEAT DEPTH RANGE
FRAME CHAIR TYPE/POWER SEATING BASE TDX5-PS TDX5 for Formula w/mk6i. $8,974 TDX4-PS TDX4 for Formula w/mk6i. $7,791 TDX3-PS TDX3 for Formula w/mk6i (includes Std MPJM6) $8,164 TRANSPORT TIE DOWN TRBKTS
Invacare TDX Series with Tilt
Date of Order: Dealer Account #: Purchasing Contact: Phone: Fax: RTS/Therapist: Ship to Address: City: Province: PC: Client Info: Gender: Special Client Conditions: 250-400 lb. weight limit. Dependent
BENTLEY. 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
BENTLEY. Order Form - AADL - W322 Prices in Canadian Dollars. October 1, W h e e l L o c k s. A n t i - T i p p e r s. B a c k P o s t S t y l e
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 * Tag Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a m e T y
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
Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018
TRACER EX2 FOLDING WHEELCHAIRS Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018 PROVIDER NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS Invacare Canada
NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS
FRAME SELECTION FRAME TYPE Seat angle is set at 3 degrees. See service manual for details. PATRIOT Folding Frame w/swingaway Front End $1,345 FRAME WIDTH W14 14'' Wide No Charge Not available with 18"
FUZE T50. Order Form USA. Please send your completed order form by to or by fax to
Page 1 of 5 Purchase Order Tag Dealer/Organization Name Purchaser Name and Contact Information Mailing Address Shipping Address Please send your completed order form by email to info@pdgmobility.com or
NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS
FOR AADL ONLY Invacare 3G Arrow Storm Series w/truetrack Suggested Canadian Price List Effective March 2nd, 2009 Revised December 1st, 2010 *UPDATED - DE CHANGES NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS
STELLAR. Order Form - USA Prices in U.S. Dollars. January 1, 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.
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
Invacare TARSYS 2G POWER TILT/RECLINE Off Chair SYSTEMS ONLY Suggested Canadian Price List Effective March 1st, 2005 Revised June 18th, 2007
Invacare TARSYS 2G POWER TILT/RECLINE Off Chair SYSTEMS ONLY Suggested Canadian Price List Effective March 1st, 2005 Revised June 18th, 2007 * UPDATED - DENOTES CHANGES NAME PHONE NO ACCOUNT # P.O. DATE
M1 - NPO. 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
STELLAR GL. Order Form - USA Prices in U.S. Dollars. January 1, 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.
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
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
Invacare 3G Ranger X Power Wheelchair
Price List and Order Form TRANSACTION TYPE: Order Quote Date Account # P.O. # Company Name Phone # Address City State Zip Code Country Contact Name Comments Special Note HCPCS codes are not intended to
NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS
Invacare 900 series Suggested Canadian Price List Effective March 2nd, 2009 NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS FRAME SELECTION ORDERING INFORMATION When ordering a 900 Series wheelchair, first select
AADL #W643 NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS
FOR AADL ONLY AADL #W643 Invacare ProSPIN X4 Ultralightweight Active Performance Folder Suggested Canadian Price List July 1st, 2013 NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS FRAME FRAME TYPE PROX4S X4
MASS Script Form. 160 Kg Weight Capacity Charge. Transit Option. 136 Kg maximum weight capacity. Not available with Removable Seat Pan.
MASS Script Form Australian Order Form Effective 05/07/2014 Company: Account Number: Date: Quote PO Number: RTS: Marked For: Ship To: Address: City: State: Zip: Phone: Email/Fax: Catalyst 5Vx K0005 Charge
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Canada AADL CAT # 151 Effective 10/01/2018 Company: Account Number: Date: q Quote q PO Number:
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
FUZE T20. Order Form - Canada Prices in Canadian Dollars. January 1, 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.
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
Company Name Account # Phone P.O. # Date. Ship to Name & Address
Price List and Order Form Effective May 18, 2009 For ease of ordering, contact customer Service Toll Free at: 800-333-6900 Fax: 800-678-4682 To order Literature: 800-828-6282 www.invacare.com Company Name
NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS
Invacare 9000 XT Wheelchair Suggested Canadian Price List Effective January 2nd, 2018 NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS Pre-Configured Stock Models Stock Chairs 9XT_PTO_29153 9XT/WD86/88-9000XT
FUZE T50. Order Form - USA Prices in U.S. Dollars. January 1, 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.
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
SpectraXTR2 HD (Modulite Flex 3 Seating or MAX System) Dealer Max User Weight 160Kg (25 stone)
Invacare Ltd Power Chair Prescription Form Pencoed Technology Park Dealer Prescription Form Pencoed CF35 5AQ LPF1U2SPECTRAXTR2HD010715DEALER Tel: +44 (0) 1656 776222 Fax: +44 (0) 1656 776220 July 2015
NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS STABLE
Invacare MyOn Active HD Folding Wheelchair AADL Customers Only AADL # W155 Effective October 1, 2018 NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS FRAME SELECTION FRAME TYPE MYONAC MyOn Active Folding Wheelchair
Page 1 of 13 INTRODUCTION PATIENT INFORMATION
Pride Mobility Products Co. For AADL use only 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Email: productorders@pridemobility.com Q6 Edge HD Order Form with TRU-Balance
NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS
BASE CHAIR TYPE/POWER SEATING BASE TDXSP-MCG TDXSP for Formula CG w/mk6i $7,205 OMIT SEAT FRAME Base only to send for aftermarket seating. OSF Omit Seat Frame for Base Only.. Less Net $390 TRANSPORT TIE
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
Quantum 1450 Group 3 Single Power Order Form Up To 600lbs Weight Capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax:
Spare Parts Catalogue. Version: 2014/10/08b EN
Spare Parts Catalogue TABLE OF CONTENTS Chassis Sideframes... Crossbrace... 5 6 Seat Seat Upholstery... Solid Seat Inserts..... 7 8 Backrest Legrests Back Cane Assemblies... 9 Back Upholstery... 10 Push
FUZE T20. Order Form - USA Prices in U.S. Dollars. January 1, 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.
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 * Tag v.070118 Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a
Parts Catalog Issued: Mar 26, Xterra GT. Power Wheelchair
Parts Catalog Issued: Mar 26, 2018 Xterra GT Power Wheelchair Parts Catalog Usage Guide The information contained in this document is subject to change without notice. This catalog contains service parts
Parts Catalog Issued: Apr 10, Pronto M94 with SureStep
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Formula CG Tilt (CGT) Powered Seating
Parts Catalog Issued: Mar 12, 2018 Formula CG Tilt (CGT) Powered Seating TDX SC2-CG w/ TDX SC & TDX SPREE-CG w/ TDX SPREE Parts Catalog Usage Guide The information contained in this document is subject
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
Quantum Q6400Z Series Group 4 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)
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
Canada Quote / Order Form Combi
Canada Quote / Order Form Combi 7105 Northland Terrace Brooklyn Park, MN 55428 Ph# 1-888-538-6872- Ext 2 Fax# 763-582-0442 Amy Jorgensen-Inside Sales AmyJ@danetechnologies.com www.levousa.com Dealer Information
FDX (Formula CGE option included) and Front Riggings
Parts Catalog Issued: Jul 16, 2018 FDX (Formula CGE option included) and Front Riggings Power Wheelchair Parts Catalog Usage Guide The information contained in this document is subject to change without
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:
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
ULTRA TDX 2. Retail Order Form Max user weight 136kg (21.4 stone) Featuring
TDX 2 ULTRA Retail Order Form Max user weight 136kg (21.4 stone) Featuring lass leading shear reduction C with our ESR Mechanism chieve the perfect fit with simple A and precise adjustment features Maximise
Pronto M50 / M51 with SureStep (After 1/19/05) Pronto M61 with SureStep
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MASS Script Form. Frame. Backrest. Seat Depth
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2004 Medicare Billing Guidelines for Rehab Products
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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
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
Company Name Account # Phone P.O. # Date. Ship to Name & Address
Invacare TD SP Rehab Seat Power Wheelchair Price List and Order Form Effective October 9, 200 Revised January 29, 2008 For ease of ordering, contact customer Service Toll Free at: 800-333-900 Fax: 800-78-482
Invacare Kite (Max Seating System) Retail Max User Weight 160Kg (25 stone)
Power Wheelchair Retail Prescription Form KITEMAX210917 Tel: 01656 776222 Fax: 01656 776220 OCTOBER 2017 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Account No : Contact
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:
Frame Width. Seating Setup. q 16 q 15 q 14 q 17 q 16 q 15 q 14 Short q 18 q 17 q 16 q 15 q 14 q 19 q 18 q 17 q 16 q 15 q 14
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:
MVP / MVP jr. (After 10/15/01) Xtra (After 8/31/04)
Parts Catalog Issued: Apr 9, 2019 MVP / MVP jr. (After 10/15/01) Xtra (After 8/31/04) Wheelchair Parts Catalog Usage Guide The information contained in this document is subject to change without notice.
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:
Standard Base Price: 539
Manual Wheelchair Retail Prescription Form ACTION3JUNIORSMALL19102018 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer
Parts Catalog Issued: Nov 10, 2006
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Parts Catalog Issued: Mar 12, Comet Rocket. Wheelchairs
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Top End Crossfire T7A Ultra Lightweight AADL Customers Only Active Performance Adjustable Rigid Wheelchair AADL # W149
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4.2 HELIO KIDS MODEL. Ultralight Folding Carbon Fiber HELIO KIDS Wheelchair Including angle & depth adjustable back (79 kg lbs weight capacity)
519, J-Oswald Forest, suite 101 Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.450 588-6555 1 866 650-6555 F.450 588-0200 www.motioncomposites.com Account : PO : Vendor : CUSTOM TECHNOLOGIES LIMITED Date
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18 Wide. MRI Transport Wheelchairs. Overall Width: 26 Wheelchair, With Fixed Footrest. Specifications:
MRI Transport Wheelchairs 18 Wide Overall Width: 26 Wheelchair, With Fixed Footrest Removable Full Length Padded Arms Fixed Footrests Seat To Floor Height: 19 1/4 Seat Width: 18 Overall Width: 26 Overall
QUICKIE TANGO... 5 BASE FRAME... 5 BATTERY BOX... 5 COVERS... 6 MAIN FRAME... 7 MOTOR MOUNT & ANTI TIP... 8 SUSPENSION... 9 MOTOR...
Title - 1 - Title - 2 - Table Of Contents QUICKIE TANGO... 5 BASE FRAME... 5 BATTERY BOX... 5 COVERS... 6 MAIN FRAME... 7 MOTOR MOUNT & ANTI TIP... 8 SUSPENSION... 9 MOTORS... 10 MOTOR... 10 SEAT/BACK...
Formula CG Tilt (CGT) Powered Seating
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Height adjustable footplates, equipped with nylon heel loops. Standard with maintenance free PU front (7 ) and rear wheels (24 ).
Excel G-lite + Compact foldable aluminium wheelchair Perfect for taking with you wherever you go due to its light transport weight and compact size. Comfortable back upholstery. Height adjustable comfortable
Invacare Action 3 Junior Basic RETAIL Max User Weight 80Kg (12.5 stone)
Manual Wheelchair Retail Prescription Form ACTION3JUNIORBASIC05122018 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer
RETAIL Max user weight: 100kg - seat widths 12" & 13" Max user weight: 130kg -seat widths 14" -16"
Manual Wheelchair Retail Prescription Form ACTION515112017 Tel: 01656 776222 Fax: 01656 776220 JAN 2018 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer Ref: Contact
SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5
PARTS CATALOG CONTENTS SIDEFRAME AND CROSSBRACE... ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5 FRONT RIGGING, DETACHABLE... 6 UPHOLSTERY... 7 ACCESSORIES...
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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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Quickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,
Quickie QXi AADL EIF6, October 2018 Mark For: Submitting for: Date: PO#: Quote Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City:
BEARINGS BEARINGS
TIRES PNEUMATIC.... 1-4 SNAP ON.....4 PRIMO HIGH PERFORMANCE......5-6 SCHWALBE HIGH PERFORMANCE.....5-6 KENDA HIGH PERFORMANCE... 7 MAINTENANCE FREE TIRES SHOX URETHANE TIRES..... 8 URETHANE TIRES....
Featuring. Customer Ref: TDX2 Ultra
Featuring Class leading shear reduction with our ESR Mechanism Achieve the perfect fit with simple and precise adjustment features Maximise comfort and pressure relief with the advanced tilt and recline
Bora. Standard Base Price 4,100. Standard Features SEAT DEPTHS
Power Wheelchair Retail Prescription Form BORAMOD121218 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
Invacare Kite (Max Seating System) Retail Max User Weight 160Kg (25 stone)
Power Wheelchair Retail Prescription Form KITEMAX160718 Tel: 01656 776222 Fax: 01656 776220 JULY 2018 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Account No : Contact No
Formula TRE Powered Seating
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JIVE F/R: 5,650 9,193 JIVE M: 5,895 9,591
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: Standard Features Angle adj. footplate
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Service Manual 3G Storm Series Wheelchairs Arrow RWD Torque SP RWD Ranger X RWD DEALER: KEEP THIS MANUAL. THE PROCEDURES IN THIS MANUAL MUST BE PERFORMED BY A QUALIFIED TECHNICIAN. Part No. 1104849 1 3G
AT MSRP Price List. Description. HCPCS Code K0020 K0020 K0106 K0106. Part Number AP3 AP4 GAP GAPS 1386/87 FUA PT0031
Client: P.O.#: AT MSRP List AP3 AP4 GAP GAPS 1386/87 FUA PT0031 3 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.
Invacare Storm4 Easy Adapt Retail Max User Weight 150kgs (23.5 stone) Standard Features
Power Wheelchair Retail Prescription Form STORM4EA010117 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2017 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
Invacare Action 3 NG Transit Retail Max User Weight 125Kg (19.7 stone)
Manual Wheelchair Retail Prescription Form ACTION3NGTRANSIT10112016 Tel: 01656 776222 Fax: 01656 776220 JAN 2017 Email: ordersuk@invacare.co.uk Online Spares available at www.invacare.co.uk Customer Ref:
SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5
PARTS CATALOG CONTENTS SIDEFRAME AND CROSSBRACE... ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5 FRONT RIGGING, DETACHABLE... 6 UPHOLSTERY... 7 ACCESSORIES...
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
Company Name Account # Phone # P.O.# Date FRAME SELECTIONS DEPTH
WIDTH Price List and Order Form Effective July 1, 200 Revised September 11, 2006 For ease of ordering, contact Customer Service Toll Free at: 800--6900 Fax: 800-678-4682 To order Literature: 800-828-6282
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Invacare Action 3 Junior Large Retail Max User Weight 80Kg (12.5 stone) Standard Base Price: 539 * Configurations may vary to the image shown
Manual Wheelchair Retail Prescription Form ACTION3JUNIORLARGE15112017 Tel: 01656 776222 Fax: 01656 776220 JAN 2018 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer Ref:
Frame. Backrest. Seat Depth. Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time free growth kit. 165 lb weight capacity.
Canada Patent Pending AADL #W157 Effective 10/01/2017 Company: Ship To: Account Number: Date: Quote PO Number: RTS: Marked For: Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time
Company Name Account # Phone # P.O.# Date. Ship To Name & Address Special Note
Price List and Order Form Effective October 9, 006 Revised April 9, 007 For ease of ordering, contact Customer Service Toll Free at: 800-333-6900 Fax: 800-678-68 To order Literature: 800-88-68 www.invacare.com
October 2018 EIQ2X. Mark For: Submitting for: Quote Order. ADDITIONAL SHIPPING INFORMATION Dealer Contact: Price. Option # 1. FRAME 002RS1 002RS2
Quickie 2 October 2018 EIQ2X Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: PV:
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: