FUSION Seating Prescription Form Custom Built Seating System
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- MargaretMargaret Burns
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1 GENERAL INFORMATION Clinician: Date: Service: Delivery Address: Client Name/Ref: Address/School: Current Equipment: Issues with Current Equipment: Observations, deformity: Hips/Pelvis: Spine/Trunk: ASSESSMENT SUMMARY Year of Birth: Diagnosis: MEASUREMENTS Current Seat a Pelvic Width: cm b Trunk Width: cm c Backrest Height: cm d Thoracic Pad Height: L R cm e Seat Depth: L R cm f Seat Ramp Length: cm g Footrest Height: L R cm h Footplate Length: cm i Knee Width: cm j Medial Pad: cm k Distance Between Knees: cm l Outside of Knees cm Backrest Recline: Seat Tilt: ORDERING INFORMATION Seat & Back Back Only Seat Only Wheelchair Model & Size: Fixed Removable Wheelchair Size: Width should be approx. 100mm wider than hip width to give 60mm width adjustment, Length approx. 70mm longer than seat depth Seat Cushion: Ramped Anti-Thrust Flat Back Cushion: inc Sacral inc Lumbar Full Type Wraparound Laterals Swingaway Laterals Arm Protraction Pads Synergel Lining Headrest : Std Curved Wing Curved Multi-Adjustable: 350mm 450mm 550mm Harness: H Type X Type Dynaflex Front Pull Rear Pull Top Pull Padded Lap Strap: 2 point 4 point Pommel Knee Laterals Footrest: CAPS II Type Wheelchair Only Footbox Foot Straps Ankle Huggers Upholstery: Black Pink Royal Blue Denim Purple Red Please see details on attached sheets We will automatically select component sizes based on client measurements however you can indicate your preference below at no extra charge. Items shown in yellow incur a small additional charge. Please record all dimensions in cm c l b k a I j d e l k f I g j
2 Seat Configuration Seat & Back Back Only Seat Only Interface into 2 wheelchairs Seat Mounting RMS Lock & Latch Fixed (Tube Clamps) Drop Seat Required Backrest Mounting 2 Pt With Tongue 2 Pt With Hinge 4 Pt mounting RMS Lock & Latch Fixed (Tube Clamps) 2 Point lock & latch with tongue is the standard option, allowing easy assembly 2 Point lock & latch with hinge mounting is suitable for smaller seats. 4 Point mounting with either lock & latch or tube clamps is primarily used with separate back support systems. Upholstery Machine washable upholstery is normally supplied in two tone with Speckle black fabric on sides and back of all covers Duratex: Black Pink Royal Blue Denim Purple Red Dartex: Black Macro Suede: Black Pink Blue Red 2 nd Set of covers, please specify: Seat Cushion Ramped Anti-Thrust Flat Sizes determined by Seat Dimensions Reflex 650F (Firm) as Standard (typically 50mm thick on flat) Further customisation available below if required. Ramp Anti-Thrust Specify b or c a) Ramp Length: b) Ramp Height: c) Ramp Angle: Ramp Base Layer: Firm (Reflex 650F) Chip Foam Flat Section of Cushion Firm Soft Med. Firm (Reflex 650F) Memory Memory Memory SynerGel Asymmetric: Left: cm Right: cm Backrest Cushion Sacral Pad Lumbar Pad Full Pad Standard Foam Memory Foam Soft Medium Firm T Shape I Shape Sacral a: b: c: d: e: f:
3 Fixed Thoracic Pelvic Swing away Lateral Supports Wrap around Thoracic Thoracic ise your laterals more: Size A B C D E F Sizes determined by Seat Dimensions Evazote padded slim line lateral pads Further customisation available below if required. L H Thoracic : L H cm Pelvic : L H cm Arm Protraction : L H cm Knee Control Solid Pommel Knee Lateral Adjustable Pommel Sizes determined by seat dimensions Solid Pommel or Knee Laterals standard Solid Pommel and Knee Laterals Adjustable Pommel Further customisation available below. Pommel Knee Laterals Size a b c d Size l h S S 15 7 M M 19 9 L L XL XL Head Support Shallow Contour Curved Size a b h Size a b h S S M M L L XL XL Wing Curved Multi Adjustable Size a b h Joints a b h S N/A 10 M / 45 N/A 10 L / 55 N/A 10 Basic Link Mount Ball & Link Through Bar (Double Ball Joints) Harnessing
4 2 Point Pelvic Belt Size determined by seat dimensions 4 Point Plastic Buckle - Single Pull Plastic Buckle - Dual Pull Safety Buckle Standard Pad Size Slim line Pad Size Shoulder Harness H-Type X-Type Dynaflex XXS Rear Pull XS Top Pull S Front Pull M L XL Foot Support Use Standard Wheelchair footplates Note: Foot supports subject to wheelchair specification Wheelchair mounted approx. Neo/Discovery std Drop Tubes Neo/Discovery Swing away Drop Tubes ABS Plastic foot box Padded foot box CAPS type footrest plates Size w l Size (inside) w l h XXS XS XS S S M M L L XL Ankle Huggers S M L Ottobock Foot Skates S M L Tray Tray mounted off Armrests, price subject to wheelchair specification Moulded Black Clear Perspex CNC Cut S M L Specify Below
5 Special Requirements / Notes or Drawings
Manufacturer: Model: Seat width: cm Seat depth: cm
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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
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Black -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
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
Synthesis Tilt Recliner Model: V4
PO: Date: Customer #: Customer Name: Address: Phone: Contact: Email: Ship To Name: Address: Phone: Contact: Tag: Standard Features Comfort Tension Seating 350lb Weight Capacity Up to 40 Infinitely Adjustable
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
Madison. Key features at a glance: Additional options:
Madison Madison The Madison Porter chair comes with a Dual Tilt in Space rise recline mechanism maximising the postural and pressure management options for the carer with independent backrest and leg
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
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
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
ALEX 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
Shower 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
JAY AES - QUICK ORDER FORM November 2012
JAY AES - QUICK ORDER FORM November 2012 Account: Date: Job #/PO#: User Name: Contact: Ship To: Name: Address: City,State,Zip: Phone: 1. WHEELCHAIR INFORMATION (REQUIRED) 3. SEAT DIMENSIONS Model: Model: