PRESCRIPTION FORM. Delivery address. Purchase order. Shipment date Delivery Date. Type

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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

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