PRESCRIPTION FORM. Delivery address. Purchase order. Shipment date Delivery Date. Type
|
|
- Sheila Oliver
- 5 years ago
- Views:
Transcription
1 PRESCRIPTION FORM Distributor Branch Client Phone Delivery address (Use 'Shift'+'Enter' for new line) Salesperson Purchase order Type Date Shipment date Delivery Date Important Demo Request Order Please fill in all neccesary information above. Remember the at top right. Lines markes Are included in stadard MG chair Select only one item within a shaded area Check ( ) to select option After selection: save the file with filename equal the "Purchase order" of this form Page 1 of 20
2 Measurements of person Measurements are done when the person is sitting in the chair BH - Height of back cm inches (2,54 cm) CH - Height of lower leg cm inches TL - Thigh length cm inches HH - Height of head cm inches AH - Height of arm cm inches AL - Length of arm cm inches FL - Length of feet cm inches HW - HIP width cm inches CW - Chest width cm inches WW - Waist width cm inches NW - Knee width cm inches Other measurements Weight kg Stones (6,35 kg) Page 2 of 20
3 Base Manual chair Power chair with Shark control system (max. 2 actuators) Power chair with Dynamic control system (max. 12 actuators) Rear wheel drive, castors in front Front wheel drive Colour of buttom frame Wheels Black, Ral 9005 White, Ral 9010 Red, Ral 3002 Yellow, Ral 1028 Blue, Ral 5010 Bronze, Ral 2013 Manual chair Drive wheels 12" with drumbrakes 16" 16" with drumbrakes 20" 24" Quickrelease axles on 16"/20"/24" Flexel Handrims on 20"/24" wheels Castors 6" 8" x 1 1/4" 8" x 2" Flexel Power chair Drive wheels 10" driving wheel with Flexel 12" driving wheel with Flexel 13" driving wheel Alu with Flexel Castors 8" x 2" 10" x 2" 10" x 2" Alu Flexel Page 3 of 20
4 Seating Width (W) in cm Wide frame Medium frame Narrow frame (ref. HW) Width in cm: (32-60cm even nos) cm Length (L) in cm Long frame Medium frame Short frame (ref. TL - 2cm) Depth in cm (38-56cm even nos) cm Height (H) in cm High frame 60 Medium frame 50 Low frame 40 Operation Tilt Fixed (Manually adjustable by tool) Gas Electric Recline Fixed (Manually adjustable by tool) Gas Electric Leg rest operation - elevation Equal L R No bearing tube (no legrest) With bearing tube (manually operated) With bearing tube and connector (Electrically operated) Page 4 of 20
5 Leg rest (s) Equal L R Identical leg rests Elevation Equal L R No elevation Manually elevation Electrically elevation Upper part in cm Equal L R (L) Long Medium Short Swing away Bracketry for calfsupport Foot rests in cm Equal L R (L) Long adjustment tube 225 Medium adjustment tube 175 Short adjustment tube 125 Foot plate(s) in cm Equal L R (L x W) All-in-One 30 x (26/36/46) (dep. of seat width) Plastic Metal Wide 23 x 16 Medium 20 x 16 Narrow 15 x 16 Large 30 x 17 Small 23 x 12 Swing away "all in one" Page 5 of 20
6 Upholstery Type of fabric Microfiber Vinyl Incontinence 3D Comfort Colour of fabric Black B Grey / Black G Red R Orange O Green G Blue B Wooden plate for seat in cm in cm Special width (W) Special length (L) Wooden plate for back in cm in cm Special width (W) Special height (H)? Page 6 of 20
7 Seat, cushions in cm Type No cushion Flat With small wedges Width buttom (WB) 24 Width top of wedges (WT) 24 Height of wedges (H) 24 Additional height at front (h) 0 With high wedges Width buttom (WB) 24 Width top of wedges (WT) 24 Height of wedges (H) 24 Additional height at front (h) 0 Ramped cushion Height at front (H) 10 Hard wedge Soft wedge Anti-trust cushion Height of anti-trust (h) 10 Length of anti-trust top (i) 10 Length of anti-trust buttom (l) 10 All cushions in cm in cm Incontinence lining Special measurements: Special width (W)? Special length (L)? Dist. front to drop (LD) Page 7 of 20
8 Backrest, cushion Type in cm No cushhion Flat cushion With thin wedges Width at buttom (WB) 0 Width at top (WT) 0 Height of wedges (H) 10 With high wedges Width at buttom (WB) 0 Width at top (WT) 0 Height of wedges (H) 10 With both thin and high wedges Width at buttom (WB) 0 Width at top (WT) 0 Height of wedges (H) 10 All cushions in cm in cm Incontinence lining Soft vertical strip for spine Special measurements: Width (W)? Height (H)? Thighness (D) Page 8 of 20
9 Armrest, cushions in cm L R L x W Medium 40 x 9 Small 35 x 8 Type L R Flat Inner edge Outer edge Double edge Page 9 of 20
10 Calf support in cm All-in-oneL R All in One H x W No calfsupport Large 26 x 19 Medium 22 x 16 Small 16 x 11 Type All-in-oneL R Flat Outer edge Left Internal height (h) 6 Right Internal height (h) 6 Inner edge Double edge With snap lock With edge(s) Outer edge, left side Inner edge Outer edge, right side Page 10 of 20
11 Lumbar support in cm W x H (cm) No Lumber support Large 34 x 10 Medium 24 x 10 Small 17 x 10 Pushing handle No pushing handle Pushbar Foldable Rotating, width & height adjustable Belts No belt Lapstrap 4 pt. Harness Chest vest with zip Page 11 of 20
12 Headrest Bracket No headrest Standard - only height adjustable Combi arm Multi-lock Multi-friction Cushion size Large Medium Small Cushion shape Flat Shallow Deep Deep left Deep right Roll Page 12 of 20
13 Thoracic supports Set of equal Thoracics Bracket Set L R No Thoracic Basic Advanced - Swing away Bracket size L R Large Medium Small Seat width > W60 W42 - W60 W32 - W40 Cushion size in cm L R H x W Large? x? Medium 13 x 20 Small 12 x 15, Page 13 of 20
14 Hip guides Bracket L R No Hip guide Basic Advanced - Swing away Cushion in cm L R L x H Large 31 x 12 Medium 29 x 9 Small 31 x 12 Basic cushion Soft cushion D 5 mm thick 10 mm thick Page 14 of 20
15 Pommel Bracket No Pommel Basic Advanced - multi adjustable Cushion in cm W 9 Square shape small H 9 L 12 W 9 Square shape large H 10 L 15 W 6,5-8,5 Wedge shape small H 9 L 12 W 6,5-8,5 Wedge shape large H 10 L 18 Knee protectors L R One size Page 15 of 20
16 Electronics for Manual Wheelchairs Hand control with wire Wireless hand control Electronics for Power Wheelchairs Dynamic Dx2-2 actuators Dynamic Dx2-4 actuators Dynamic DX - REMG90 Shark - 2 actuators Joystick right hand side Joystick left hand side Swing away arm for joystick Dual control (Secondary remote for attandant) Chin control Page 16 of 20
17 Other electronic (Use 'Shift'+'Enter' for new line) Page 17 of 20
18 Tray No Tray No cut Cut for joystick Cut for swing away joystick No edges Short edged Long edges Cushions for tray Inner cushion Incontinence lining Outer cushion Incontinence lining Page 18 of 20
19 Settings Seating height From seat cushion top to footplate a in cm From seat cushion top to floor b in cm Extended base length + 40 mm Extended base width 0 cm 5 cm 10 cm Centre of gravity cm in cm Armrest height cm in cm Armrest angle in degrees Front of arm pads-to-backrest distance in cm Distance between armrest in cm Page 19 of 20
20 Other notes (Use 'Shift'+'Enter' for new line) Page 20 of 20
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
More informationJIVE 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
More informationR82 Wombat Living. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: Date: Wombat Living Standard Features:
Account #: Purchase Order No.: Date: Contact: R82 Wombat Living CAD Retail Price List/ Order Form Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Wombat
More informationOrderform UK / IR Valid from Version 2.1 LUCA QLASS. Date:
LUCA QLASS 1 / 8 0,8 Dealer: Date: Reference No.: Quantity: Delivery address: 4.650 3.720 Basic configuration Excluding VAT - 4mph/6 km/h RWD - Fixed joystick bracket, right hand - PU side cushions - Drive
More informationBasic 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
More informationInvacare 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
More informationALEX QLASS. Order form. T: +44 (0) F: +44 (0)
Order form ALEX QLASS T: +44 (0)8450 745 945 F: +44 (0)8450 745 946 mobilityorders@handicare.co.uk www.handicare.co.uk Valid from 1-4-2015 Version 1.0 Dealer Date Reference No. Delivery address Quantity
More informationInvacare REA Azalea Transit RETAIL Max User Weight 135Kg (21 stone)
Manual Wheelchair Retail Prescription Form ReaAzaleaTransit281117 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com January 2018 Online spares available at: www.invacare.co.uk Customer Ref:
More informationOrderform UK / IR Valid from Version 2.1. Alex QLASS. Date:
Alex QLASS 1 / 8 0,8 Dealer: Date: Reference No.: Quantity: Delivery address: 6.948 5.559 Basic configuration Excluding VAT - 4mph/6 km/h RWD - Battery charger 8A -24 V - Armrests standard removable -
More informationPlease choose the seat width for accessories: 35 cm 40 cm 43 cm 45 cm 50 cm
Netti 4U comfort fully adjustable Date Invoice address Invoice address = delivery address Customer code C- Contact person Reference Other delivery address Offer Order Basic price: 2.750,- excl. VAT. Seat
More informationCanada 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
More informationx: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
More informationSpectraXTR2 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
More informationCustomer code C- Invoice address. Max. 90 kg See page 5 Side upholstery (reduces SW with 2 x 2 cm) = Standard equipment
Date Customer code C- Invoice address Contact person Reference Other delivery address Quote Invoice address = delivery address Basic price: 3.495,- excl. VAT Seat width D2025 D2030 D2035 25 cm 30 cm 35
More informationOrder form LEVO LAE 2011/1
Seat height 48 Seat height 51 Seat height 54 Seat height 57 Order form LEVO LAE 2011/1 Please answer the following questions exactly and consider the indications.the exact measurement within the pictograms
More informationCanadian Suggested Retail Price List April 2015
Size 5 Canadian Suggested Retail Price List April 2015 Account No. Drop Ship: Date: Name P.O. Number: Address Buyer: City Marked For: State Zip E Mail: Tel. Fax A ( Back height) B (Arm height) C (Lower
More informationBlack -01 Moss green -95 Yellow -99. Heather purple -97. Indicate height. Indicate height. Indicate angle. Indicate height: cm. Indicate height: cm
Cross 5 XL Prescription form 75188K 017-05-08 Reference: Name: Tel: Date: version is marked with The measurements given can vary ±% Short frame Seat width (cm) Seat depth 36-4 (-49*)cm Measured from back
More informationFUSION Seating Prescription Form Custom Built Seating System
GENERAL INFORMATION Clinician: Email: Date: Service: Delivery Address: Client Name/Ref: Address/School: Current Equipment: Issues with Current Equipment: Observations, deformity: Hips/Pelvis: Spine/Trunk:
More informationStandard Base Price: 618
Manual Wheelchair Retail Prescription Form ACTION4NGHD11112016 Tel: 01656 776222 Fax: 01656 776220 JAN 2017 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref: Contact
More informationR82 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
More informationInvacare 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:
More informationTraxx 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
More informationQLASS OPTIONS SAMM / ALEX / LUCA
QLASS OPTIONS SAMM / ALEX / LUCA OPTIONS CONTROLS AND LIGHTING B000156 B000157 B000158 B000714 B000715 Dynamic Shark drive only - Lighting: no - Powered options: no Dynamic Shark lights - Powered options:
More informationR82 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
More informationLEVO combi. The Mid-Wheel power wheelchair with stand-up function and complete seating systems. LEVO combi. LEVO stands for a better quality of life
LEVO combi The Mid-Wheel power wheelchair with stand-up function and complete seating systems LEVO combi LEVO stands for a better quality of life At eye level with life This is LEVO: The touch of a switch
More informationDealer Please check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm
EVO CEV Order form Dealer 2017 EVO Dealer: Date: Dealer reference / Client name: Order number: Anglikerstrasse 20 CH-5610 Wohlen Phone: +41 56 618 44 11 Fax: +41 56 618 44 10 e-mail: office@levo.ch configuration
More informationInvacare 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
More informationPage 1/133. Price and ordering list. Mustang B (Shoulder height)
Page 1/133 Valid from: #REF! Configuration A (Total height) Mustang B (Shoulder height) Accessories: C (Chest height) Chest support, adjustable D (Buttock height) Head support E (Chest width) Back support
More informationStandard 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
More informationR82 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
More informationStandard 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
More informationR82 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
More informationPlease check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm
EVO AE Order form Dealer 2017 EVO Dealer: Date: Dealer reference / Client name: Order number: Anglikerstrasse 20 CH-5610 Wohlen Phone: +41 56 618 44 11 Fax: +41 56 618 44 10 e-mail: office@levo.ch configuration
More informationOptimise your fleet management. A choice of seven wheelchairs, created around one concept.
New X Family 2 Optimise your fleet management. A choice of seven wheelchairs, created around one concept. Highly flexible configurations make the chairs easy to reconfigure and reissue Interchangeable
More informationAquatec Ocean Family. Ocean Family. Aquatec
The Ocean series of shower commode chairs offers a flexible, modular solution for a wide range of clients. The range consists of transit, self-propel, tilt in space as well as powered tilt and recline
More informationPower. Compact yet powerful at home outside as well as inside! Configured Salsa with Comfort Seating and powered elevating legrests
Compact yet powerful at home outside as well as inside! Configured Salsa with Comfort Seating and powered elevating legrests Compact dimensions for indoor mobility Low seat height for easy table access
More informationInvacare 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
More informationFor 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
More informationAquatec. Ocean Family. Flexible, modular shower chair commode solutions
Aquatec Ocean Family Flexible, modular shower chair commode solutions A range of high quality, modular, stainless steel shower chair commodes that are designed to support a wide range of clients and conditions.
More informationPhone: 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
More informationTango. Setting a new standard in powered wheelchairs. Comprehensive standard configuration includes:
Setting a new standard in powered wheelchairs The Quickie Tango is THE complete, flexible and cost-effective indoor/outdoor powered wheelchair solution. Comprehensive standard configuration includes: Powered
More informationInvacare 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
More informationAccessories brochure
Accessories brochure NEW The Invacare Rea Passive range, with its tilt and recline chairs is compatible with a wide variety of accessories, giving users the opportunity to achieve an optimal fit, and greater
More informationC350 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
More informationC300 Corpus VR2. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
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
More informationULTRA 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
More informationEtac Prio. A comfort wheelchair with unique innovations.
Etac Prio A comfort wheelchair with unique innovations. Etac Prio dynamic comfort By changing seat and back angles and adjusting the elevating leg supports, you can vary body position and pressure points,
More informationInvacare 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:
More informationPhone: 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:
More informationSEATING CHOICE TITANIUM FRONT FRAME
Manual Wheelchair Retail Prescription Form Champion140618 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk July 2018 Account No : Contact
More informationOrder no.: ... Date Signature. Posterior seat height
Start M6 Junior Scripted Order no.: Start M6 Junior Lightweight wheelchair Article number: 480F53=60000_K Provide estimate only Order Billing address/customer number Ottobock START_M6_647F263=EN-05-1510
More informationComfort Wheelchairs. Forr Mobility Frithfield Farm Aldington Ashford Kent TN257HH
Comfort Wheelchairs Forr Mobility Frithfield Farm Aldington Ashford Kent TN257HH 01233 721589 www.forrmobility.co.uk ID Soft Drive Medical Seat widths 15-21 39-53 cm Seat depth 16-18 40-46 cm Overall width
More informationX850 Corpus. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
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
More informationTilt in space up to 60 degrees Comfort seating Max. user weight: 113kg. Height adjustable folding back Heavy Duty version 158kg
QUICKIE IRIS Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: E-Mail: E-Mail: Tel: Fax: Tel: Order date: Marked for: Purchase order: Number required: Sunrise order no: Base
More information, , Indicate height. Indicate height. Indicate angle. Indicate height: cm
ross 5 Prescription form 7586J 07-05-08 Reference: Name: Tel: ate: Standard version is marked with The measurements given can vary ±% Short frame Seat width (cm) Seat depth 36-4 (-49*)cm Measured from
More informationSHIPPING 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
More informationcp tech customised product technology Product Catalogue
cp tech customised product technology Product Catalogue CONTENTS 1. How to Measure a Postural Insert 2. Insert Components - Back and Base - Cushions - Lateral Supports - Head Supports - Pommels - Foot
More informationEtac Cross 5 and Cross 5 XL
Etac Cross 5 and Cross 5 XL The new generation wheelchair with the optimum prerequisites for delivering comfort and excellent manoeuvrability. Etac Cross 5 when every little detail makes a big difference
More informationPlease make your selection with a cross in the box Standard feature Free of Charge
Manual Wheelchair Retail Prescription Form Champion161116 Tel: 01656776222 Fax: 01656776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk JANUARY 2017 Account No : Built in
More informationchampion carbon Customer weight = Kg Code X Description Dealer SEATING CHOICE DDF0204 küschall Champion Carbon 85 Frame Angle
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed. CF35 5AQ LPF1U2CHAMPION211114D Tel: 01656 776222 Fax: 01656 776220 LPF0015Z email: ordersuk@invacare.com January
More informationInvacare FOX (Modulite Seating System) Retail Max User Weight 127Kg (20 stone)
Power Wheelchair Retail Prescription Form FOXMOD210917 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk OCTOBER 2017 Customer Ref : Account
More informationBora. 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
More information2016 EZ RIDER UPRIGHT PRODUCT PPT
2016 EZ RIDER UPRIGHT PRODUCT PPT By Nancy Guzman 310.618.0111, Ext. 143 nancyg@convaid.com Product Overview EZ RIDER 10 Fixed Tilt Customizable Multiple Upholstery Styles & Colors 5 years of Growth Capabilities
More informationSetting a new standard in powered wheelchairs
Setting a new standard in powered wheelchairs The Quickie Tango is THE complete, flexible and cost-effective indoor/outdoor powered wheelchair solution. Comprehensive standard configuration includes: Powered
More informationManufacturer: Model: Seat width: cm Seat depth: cm
Thompson House Unit 10, Styles Close, Sittingbourne, Kent ME10 3BF Tel: 01795 477280 Fax: 01795 229692 Email: sales@rms-kent.co.uk web: www.ineedawheelchair.co.uk Caddy modular seating system order form
More informationBENTLEY. 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
More informationBENTLEY. 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
More informationVelocity 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
More informationFUZE 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
More informationchampion Standard Base Price 1,875 Standard Features
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed. CF35 5AQ LPF1U2CHAMPION290514D Tel: 01656 776222 Fax: 01656 776220 LPF0015Z email: ordersuk@invacare.com January
More informationATP 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:
More informationFUZE 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
More informationOrder Date : carbon. Tension adjustable seat, option DDA0611 is not possible with seat width 320mm
Manual Wheelchair Retail Prescription Form KSeriesCarbon061218 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk January 2019 Customer Ref:
More informationR82 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
More informationSTELLAR. 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
More informationM1 - 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
More informationBreezy 250. Strong and durable... Good looks... Complete range of models and accessories... Great warranty and after-sales service...
Breezy 250 Breezy 250 Strong and durable... Good looks... Complete range of models and accessories... Great warranty and after-sales service... Breezy 250 shown with non-standard options Strong and durable
More informationC350 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
More informationInvacare 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
More information, , Black -01 Coral -96 Yellow -99. Heather purple -97.
ross 5 Prescription form 7586 06--03 Reference: Name: Tel: ate: version is marked with The measurements given can vary ±% Short frame Seat width (cm) Seat depth 36-4 (-49*)cm Measured from back post (*Triangular
More informationR82 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
More informationR82 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
More informationMygo Seat Spare Parts Catalogue
Mygo Seat Spare Parts Catalogue Contents 03-04 Mygo Seat Complete 05 Backrest Assembly 06 LH Footrest Assembly 07 RH Footrest Assembly 08 Size 1 Abduction Assembly 09-10 Size 2 Abduction Assembly 11 Seatbase
More informationConvaid 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
More informationC350 PS VR2. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
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
More informationConvaid 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
More informationThe Porta Range. Our complete mobile and adjustable transfer chairs.
The Porta Range Our complete mobile and adjustable transfer chairs. Our family of Porter chairs offer a Long-Term Postural and Pressure Management Seating Solution. Suitable Environments Home Nursing &
More informationMargolis Summer Special Offer Ergo Human Chairs. Only vat!!! Margolis Office Interiors Ltd, 341 Euston Road, London NW1 3AD
Margolis Summer Special Offer Ergo Human Chairs Only 360 + vat!!! Margolis Office Interiors Ltd, 341 Euston Road, London NW1 3AD Tel: 020 7504 3460, Fax: 020 7388 0625 www.margolisfurniture.co.uk Ergonomic
More informationKüschall Ultra Light RETAIL Maximum user weight 130kg (20.5 Stone)
Manual Wheelchair Retail Prescription Form UltraLight061216 Tel: 01656776222 Fax: 01656776220 Email: ordersuk@invacare.com JANUARY 2017 Online spares available at: www.invacare.co.uk Account No : Built
More informationASSEMBLY AND USER GUIDE
ASSEMBLY AND USER GUIDE "DESIGNED FOR THE OPTIMAL GAMING EXPERIENCE AND UNPARALLELED COMFORT" Congratulations on purchasing your EDGE GX1 gaming chair. The chair has several important adjustments. Spending
More informationk-series Aluminium Standard Features
Manual Wheelchair Retail Prescription Form KSeries200618 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk July 2018 Customer Ref: Account
More informationSymmetriKit TM 2010 chairs. for rest, work and play
SymmetriKit TM 2010 chairs for rest, work and play Beth having a stretch in prone Multi-functional One piece of furniture for tilt in space sitting, reclining and side lying. Use it head down for postural
More informationQUICKIE 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...
More informationShower commode chairs
Ocean, Ocean XL, Ocean Vip, Ocean ual Vip, The Ocean series of shower commode chairs offers the right model for all demands. www.clarkehealthcare.com 888-347-4537 17 Ocean Stable, stainless steel frame
More informationLIVE 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
More informationSHIPPING 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
More informationHeight 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
More informationMulti Bari. Key features at a glance: Additional options:
Multi Bari 2 Multi Bari Designed for comfort and pressure management control, the Multi Bari has removable waterfall back cushions that can be individually positioned and re-positioned for comfort with
More informationNote 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:
More informationZIPPIE SALSA R2 - CHASSIS
Title - 1 - Table Of Contents ZIPPIE SALSA R2 / ZIPPIE SALSA M2... 4 FRAME AND BATTERY BOX... 4 ZIPPIE SALSA R2 - CHASSIS... 4 ZIPPIE SALSA M2 - CHASSIS... 5 ZIPPIE SALSA R2 - SEAT HEIGHT EXTENSION KIT...
More information