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.
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1 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.
2 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.
3 Client: P.O.#: X8 MSRP List 1325 Directional Lock (used to reverse in straight line) $1, * HEADREST MPS 1370 MPS Headrest $ Rehab HD-MF Comfort Company Moldable Headrest Pad $ E0955 HD-BH Removable Multi-Axis Headrest Hardware $ E1028 LATERAL SUPPORTS MPS LT1-SA Comfort Company Single Swingaway Lateral Hardware Right Left $400.00/ea E0 56 LT1-L/RS4W4T Comfort Company Single Lateral Pad 5 W x 4 T, Stretch-Air Cover $53/ea E1028 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 Right Left CHOOSE JOYSTICK TYPE: DXREM420 Standard Joystick Module. No LCD Display and No Mono Jacks DX2 Color LCD Display w/mono Jack Ports for External Switches $ E2323 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: Left - Adjustable Depth Right- Adjustable Depth Swingaway Joystick Left Right $ E2323 Midline Mount Left 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 Bibmount (Mini) Stealth Switch-It Swingaway Headrest Mount Call for Quote ENVIRONMENTAL CONTROLS: iportalacc Control Unit - Integrates Apple Devices (iphone, ipod, ipad) into Dynamic Control System through Blue Tooth Connection $ iportacc + Mouse Move 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 I2010 Knee Adductors; Multi-Axis; Removable with 4.5x6 Pad $380.00
4 Client: P.O.#: X8 MSRP List 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 $ $ Transit Hooks (WC 19 Compliant) with Lap Belt $ X8 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) RDC X8 MPS Seating System or Rehab Seating and No Power Seating Options X8 50 Power TIS* X8 Rehab Seating System w/ 135 Integrated Shear Reduction (ISR) Power Recline* X8 MPS Seating System w/ 135 Power Recline* X8 12 Seat Elevator* lb. Capacity Reduced Drive Capability TIS Seat Elevator (Option for driving while elevated and/or tilted) Must be ordered with upgraded electronics SFCK or MFCK depending on number of options selected $2, $4, $4, $3, $4, $700.00/ea. K0108 E1002 E1004 E1003 E2300 K0108 SFC Single Seat Function Control it - Function through oystick For operation of a single seat function through the wheelchair electronics via the drive controls and/or membrane switch. TOG2 Separate Toggle $ E2310 $ (add for separate toggle) MFC Multiple Seat Function Control it - Function through oystick M T be selected if ordering two or more seat functions. This device is used to operate two or $ E2311 more seat functions through the wheelchair electronics via the drive controls and/or membrane switch. TOG4 Separate Toggle $ (add for separate toggle) 12 x x x x x x x x x x x x x x x x Standard MPS Seat Back 22 4 Extra Tall Seat Back All inyl Seat Back 4 Extra Tall Seat Back - All inyl $ $ $ C -FN 46G M2-F B -M B -R B - Curve ushion - Molded foam w/ medial lateral thigh supports - si e: W x L Elements ushion - Single layer foam with uadra gel pack - si e: W x L M2 ushion - uadra gel with pelvic lateral medial thigh supports - si e: W x L ACTA - ac - with moldable center section and high resiliency wings circle height: Radius ac - with high resiliency foam circle height: isco Back - with high resiliency foam circle height: $86.00 $86.00 $ $ $ $ E2601 E2601 E2607 E2613 E2611 E2611
5 Client: P.O.#: X8 MSRP List 13 6 Removable Clear Polycarb Table (May not work w/ some options) $ E Waterproof Wheelchair Cover $ Waterproof oystick Cover $ Deluxe Backpack $ Armrest Bag $ Full Lighting it- 2 headlights 2 Red Marker Lights w/turn Signals through oystick $ /1137/1363 Luggage Rack $ PT0035 Cane Holder (May not work w/some options) $ PT0052 Cup Holder $ PT0036 Lift Brackets- sed with 4-Point Boom Lift (NOT approved as transport tie downs) $ A02H Articulating Oxygen Holder $ PWB Power Buddy- Includes SB Charging Port and Reading Light $ C All Terrain Tire Complete w/ Rim Single Pair $175.00/ea ack $ LGS C Lift Gate Service (For facilites without dock) $ *discounts do not apply BAT BCSTD BAT-G Group 24 Sealed LA/AGM, Installed (Two Required) Battery Charger Group 24 Sealed Gel Installed $275.00/ea. $325.00/ea. E2363 E2363 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 IIIQTR2014.
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.
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
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
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:
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
SHIPPING INFORMATION Provider Acct #:
May 2014 Kid's ROCK TM Size 3 Order Form Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
Convaid Trekker 2 - HCPCS E1234 Retail Price List / Order Form
Account #: Contact: Retail Price List / Order Form Purchase Order #: Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email: Ship To: Address: City/State/Zip: Phone: TR14 Base Accepts TR12 & TR14
SHIPPING INFORMATION Provider Acct #:
May 2014 Kids ROCK TM Size 2 Order Form Maximum Weight Capacity 115 lbs. 14"Wx16"Dx22"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
Convaid Trekker 2 - HCPCS E1234 Canadian Retail Price List / Order Form
Account #: Contact: Canadian Retail Price List / Order Form Purchase Order #: Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email: Ship To: Address: City/State/Zip: Phone: TR14 Base Accepts
C300 Corpus Tilt. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the
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:
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
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
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
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
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
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
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
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:
SHIPPING INFORMATION Provider Acct #: Address: ST: ZIP:
May 2014 Kids FAST Order Form Maximum Weight Capacity 80 lbs. 12"Wx14.5"Dx19.5"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
Positioning Components Order Form - ODJFS Only
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Positioning Components Order Form - ODJFS Only Account Number: Date: Provider
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
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)
Velocity Order Form. Dealer Information Dealer Name ATP Account Number Phone Fax Date PO# Ship to Address City State Zip
1-800-963-7487 Fax: 239-772-3252 Velocity Order Form Dealer Information Dealer Name ATP Account Number Phone Fax E-Mail Date PO# Ship to Address City State Zip Client Information Weight Height Seat-to-Floor
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:
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
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
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:
Quickie QM-7 Series. Live Without Limits. Available in Eight Group 3 and Group 4 Models:
Power Portfolio Live Without Limits The Quickie QM-7 series offers a high-performing, reliable, and stylish mid-wheel drive power solution for a client who qualifies for a Group 3 Standard (QM-710), Group
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
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
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:
ZM-310. Table of Contents. Why Quickie? Compact Base with Serious Power! Positioning Options. Pediatric Seating
Power Portfolio Table of Contents Zippie ZM-310...2 Quickie QM-7 Series...3 Quickie Pulse Series...6 Quickie S-6 Series...8 Quickie P-222 SE...10 PG Drives Technology...12 Back Upholstery Options...12
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
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
Quickie QM-7 Series. Live Without Limits. Available in Eight Group 3 and Group 4 Models:
Power Portfolio Live Without Limits The Quickie QM-7 series offers a high-performing, reliable, and stylish mid-wheel drive power solution for a client who qualifies for a Group 3 Standard (QM-710), Group
Traxx 3 & Atigra 2 Script Form
Traxx 3 & Atigra 2 Script Form Client Information Address Therapist Information Organisation Email Phone Height Weight Funding Source Salesperson Information Company Traxx 3 Atigra 2 Standard Features
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
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
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
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
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
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
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:
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
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
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
MASS Script Form. Frame. Backrest. Seat Depth
MASS Script Form Company: Account Number: Date: Quote PO Number: RTS: Marked For: Australian Order Order Effective 01/10/2014 Ship To: Address: City: State: Zip: Phone: Email/Fax: Rogue XP K0005, E1235
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
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
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
x:panda, size 1, med. back X c x:panda, size 1, med. seat 7¼" X c
Account No. Drop Ship: Date: Name P.O. Number: Address Buyer: City Marked For: State Zip E Mail: Tel. Fax Features included in standard price: Height, Depth & Angle Adjustable Back Angle Adjustable Adduction
Basic price 2.250,- Excl. VAT
Date Invoice address Invoice address = delivery address Customer code C- Contact person Reference Other delivery address Quote Seat width D64035 35 cm D64040 40 cm D64045 45 cm D64050 50 cm = Standard
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
Quantum R4000 Series Group 3 Single Power & Multiple Power Order Form / ODJSF 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) 707-3422 Quantum R4000 Series Group 3 Single Power & Multiple Power
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
Quantum Q1121 Series Group 3 Single Power and Multiple Power 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 Q1121 Series Group 3 Single Power and Multiple Power
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:
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
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.
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
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 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
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)
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
C350 Corpus 3G. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
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ADJUSTER LOW & ADJUSTER DER FM HCPCS CODING: E2622/E2623 - ADJUSTABLE SKIN PROTECTION Adjuster Low Adjuster Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference: Fax:
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Quantum R4000 Series Group 3 Standard Order Form 300 lbs. weight capacity
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Q6 Edge HD Order Form with TRU-Balance 3 Positioning - Group 3, ODJFS Only
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* 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
Page 1 of 13 INTRODUCTION PATIENT INFORMATION
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2004 Medicare Billing Guidelines for Rehab Products
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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
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Vision Ultra-single power
Account # Dealer Name Contact Phone Date Fax E-Mail PO Number Ship to Address City State Zip *HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers