This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows.
|
|
|
- Brendan Fox
- 5 years ago
- Views:
Transcription
1 This form must be opened in dobe crobat. The Submit Form button will not work from most browser windows. Company: ccount Number: Date: Quote PO Number: RTS: Ship To: ddress: City: State: Zip: Phone: Marked For: /Fax: Effective 04/08/2019 xiom ack xiom Posterior ack (P) Retail (Each) $555 $555 $555 $555 $555 $791 HCPC E2613 E2613 E2613 E2613 E2613 E2614 Part Number XP1208 XP1408 XP1608 XP1808 XP2008 Part Number XP1410 XP1610 XP1810 XP2010 XP2210 Part Number XP1212 XP1412 XP1612 XP1812 XP2012 Part Number XP1414 XP1614 XP1814 XP2014 XP2214 Part Number XP1216 XP1416 XP1616 XP1816 XP2016 Part Number XP1418 XP1618 XP1818 XP2018 XP2218 Gloss Finish Gloss Finish Matte Finish Matte Finish xiom Posterior ack Measurement Reference ack Depth xiom Posterior ack - xiom Posterior ack - HCPCS codes provided are based on code verification by the PDC or our interpretation of the code definitions. Proper use of HCPCS codes does not ensure coverage or payment. For coverage information, verify the appropriate payer s coverage policy. DCN Pricing and specifications subject to change without notice Page 1 of 7
2 xiom ack continued xiom Posterior Lateral ack (PL) Retail (Each) $636 $636 $636 $636 $636 $862 HCPC E2615 E2615 E2615 E2615 E2615 E2616 Part Number XPL1208 XPL1408 XPL1608 XPL1808 XPL Part Number XPL1410 XPL1610 XPL1810 XPL2010 XPL Part Number XPL1212 XPL1412 XPL1612 XPL1812 XPL Part Number XPL1414 XPL1614 XPL1814 XPL2014 XPL2214 Part Number XPL1216 XPL1416 XPL1616 XPL1816 XPL2016 Part Number XPL1418 XPL1618 XPL1818 XPL2018 XPL2218 Part Number XPL1220 XPL1420 XPL1620 XPL1820 XPL Part Number XPL1422 XPL1622 XPL1822 XPL2022 XPL Gloss Finish Gloss Finish Matte Finish Matte Finish xiom Posterior Lateral ack Measurement Reference ack Depth xiom Posterior Lateral ack - xiom Posterior Lateral ack - xiom Posterior Lateral ack DCN Pricing and specifications subject to change without notice Page 2 of 7
3 xiom ack continued xiom Lateral ack (L) Retail (Each) $735 $735 $735 $735 $735 $813 HCPC E2620 E2620 E2620 E2620 E2620 E2621 Part Number XL1208 XL1408 XL1608 XL1808 XL Part Number XL1410 XL1610 XL1810 XL2010 XL Part Number XL1212 XL1412 XL1612 XL1812 XL Part Number XL1414 XL1614 XL1814 XL2014 XL2214 Part Number XL1216 XL1416 XL1616 XL1816 XL2016 Part Number XL1418 XL1618 XL1818 XL2018 XL2218 Part Number XL1220 XL1420 XL1620 XL1820 XL Part Number XL1422 XL1622 XL1822 XL2022 XL Gloss Finish Gloss Finish Matte Finish Matte Finish xiom Lateral ack Measurement Reference ack Depth xiom Lateral ack - xiom Lateral ack - xiom Lateral ack DCN Pricing and specifications subject to change without notice Page 3 of 7
4 xiom ack continued xiom Deep Lateral ack (DL) Retail (Each) $735 $735 $735 $735 $735 $813 HCPC E2620 E2620 E2620 E2620 E2620 E2621 Part Number XDL1214 XDL1414 XDL1614 XDL1814 XDL2014 XDL2214 Part Number XDL1416 XDL1616 XDL1816 XDL2016 Part Number XDL1218 XDL1418 XDL1618 XDL1818 XDL2018 XDL2218 Part Number XDL1220 XDL1420 XDL1620 XDL1820 XDL2020 Part Number XDL1422 XDL1622 XDL1822 XDL2022 XDL2222 Gloss Finish Gloss Finish Matte Finish Matte Finish xiom Deep Lateral ack Measurement Reference ack Depth Measurement based on back width xiom Deep Lateral ack - xiom Deep Lateral ack - DCN Pricing and specifications subject to change without notice Page 4 of 7
5 xiom ack ccessories Headrest and Hardware Fill uantity needed in the box corresponding with the headrest and hardware combination in chart below. vailable only on or backs. CP450 CP250 CP150 P250 P350 P450 TCP205 TCP105 HMO400 HMO475-1 TW480-1 Hardware Standard Straight ack Mount Hardware with 1 all Multi xis Removable Hardware w/1 Horizontal ar Headrest Hardware with 1 all HMO400 HMO475-1 TW480-1 Description Item Code HCPC Kio Code Retail (Each) Kio Code Retail (Each) Kio Code Retail (Each) Comfort Plus Headrest 8 CP450 E0955 HDR001 $277 HDR009 $313 HDR017 $388 Comfort Plus Headrest 10 CP250 E0955 HDR002 $277 HDR010 $313 HDR018 $388 Headrest Pad Comfort Plus Headrest CP150 E0955 HDR003 $277 HDR011 $313 HDR019 $388 Small ll Positioning Headrest Pad and Ring Only Medium ll Positioning Headrest Pad and Ring Only Large ll Positioning Headrest Pad and Ring Only P250 E0955 HDR004 $277 HDR012 $313 HDR020 $388 P350 E0955 HDR005 $277 HDR013 $313 HDR021 $388 P450 E0955 HDR006 $277 HDR014 $313 HDR022 $388 Tri-Comfort Plus Headrest TCP205 E0955 HDR007 $288 HDR015 $324 HDR023 $399 Tri-Comfort Plus Headrest 19 TCP105 E0955 HDR008 $288 HDR016 $324 HDR024 $399 Universal Mounting Hardware For use with other manufacturer headrests Description Item Code HCPC Retail (Each) Universal Mounting Plate UMP K0108 $40 DCN Pricing and specifications subject to change without notice Page 5 of 7
6 xiom ack ccessories continued Lateral Support Sold in pairs Description Item Code HCPC Retail (Each) Laterals for Posterior ack 3 x 4 Lateral Pads with Fixed Mounting Hardware for xiom Posterior ack 4 x 5 Lateral Pads with Fixed Mounting Hardware for xiom Posterior ack 3 x 4 Lateral Pads with Swing way Mounting Hardware for xiom Posterior ack 4 x 5 Lateral Pads with Swing way Mounting Hardware for xiom Posterior ack Laterals for Posterior Lateral ack and Lateral ack 3 x 4 Lateral Pads with Fixed Mounting Hardware for xiom Posterior Lateral and xiom Lateral acks 4 x 5 Lateral Pads with Fixed Mounting Hardware for xiom Posterior Lateral and xiom Lateral acks 3 x 4 Lateral Pads with Swing way Mounting Hardware for xiom Posterior Lateral and xiom Lateral acks 4 x 5 Lateral Pads with Swing way Mounting Hardware for xiom Posterior Lateral and xiom Lateral acks LF3x4P E0956 $305 LF4x5P E0956 $305 LS3x4P E0956, E1028 $650 LS4x5P E0956, E1028 $650 LF3x4L E0956 $305 LF4x5L E0956 $305 LS3x4L E0956, E1028 $650 LS4x5L E0956, E1028 $650 Lumbar Pads vailable only with xiom Lateral ack and xiom Deep Lateral ack Description Item Code HCPC Retail (Each) Lumbar Pad 12 L12 K0108 $48 Lumbar Pad L14 K0108 $48 Lumbar Pad L16 K0108 $48 Lumbar Pad L18 K0108 $48 Lumbar Pad 20 L20 K0108 $48 Lumbar Pad 22 L22 K0108 $48 Privacy Flap Description Item Code HCPC Retail (Each) Privacy Flap 12 PF12 K0108 $45 Privacy Flap PF14 K0108 $45 Privacy Flap PF16 K0108 $45 Privacy Flap PF18 K0108 $45 Privacy Flap 20 PF20 K0108 $45 Privacy Flap 22 PF22 K0108 $45 DCN Pricing and specifications subject to change without notice Page 6 of 7
7 xiom ack ccessories continued Therafin Posture Support Description Item Code HCPC Retail (Each) Small Static Therafit 2-Piece Chest Strap with H & L dj and 1 Safety Strap 60153T E0960 $144 Medium Static Therafit 2-Piece Chest Strap with H & L dj and 1 Safety Strap 60154T E0960 $144 Large Static Therafit 2-Piece Chest Strap with H & L dj and 1 Safety Strap 60155T E0960 $144 Small Dynamic Therafit Chest Strap with Dual D-Ring djustment 60110T E0960 $113 Medium Dynamic Therafit Chest Strap with Dual D-Ring djustment 60111T E0960 $113 Large Dynamic Therafit Chest Strap with Dual D-Ring djustment 60112T E0960 $113 Small Dynamic Therafit Comfortfit Full Vest 30589T E0960 $167 Medum Dynamic Therafit Comfortfit Full Vest 30590T E0960 $167 Large Dynamic Therafit Comfortfit Full Vest 30591T E0960 $167 XLarge Dynamic Therafit Comfortfit Full Vest 30592T E0960 $167 XXLarge Dynamic Therafit Comfortfit Full Vest 30593T E0960 $167 Small Dynamic Therafit Comfortfit Trim Vest 30618T E0960 $169 Medum Dynamic Therafit Comfortfit Trim Vest 30619T E0960 $169 Large Dynamic Therafit Comfortfit Trim Vest 30620T E0960 $169 XLarge Dynamic Therafit Comfortfit Trim Vest 30621T E0960 $169 XXLarge Dynamic Therafit Comfortfit Trim Vest 30622T E0960 $169 xiom ack Modifications Extended lead times will apply xiom ack Modifications Description Item Code HCPC Retail (Each) Modification for 4 Point Harness XM4PT K0108 N/C Modification for 2 Point Chest Strap XM2PT K0108 N/C Modification for Shoulder Guides Includes shoulder guides XMSG K0108 $50 DCN Pricing and specifications subject to change without notice Page 7 of 7
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows.
This form must be opened in dobe crobat. The Submit Form button will not work from most browser windows. Company: ccount Number: Date: Quote PO Number: RTS: Ship To: ddress: City: State: Zip: Phone: Marked
Quick Reference J3 Back Guide
Quick Reference J3 Back Guide OVERVIEW STEP 1 Conur Depth For a cusm-fit J3 Backrest, follow this 5-Step Guide determine your J3 Smart Part Number. STEP 2 Level of Support STEP 3 Back Support Height STEP
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
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
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
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
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
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
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:
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
SETING PCKGES (ll Packages Shown with Quick Release Hardware) SOLID SET Seating Configuration Diagram on Page 3 Code/s: E2607 or E2608 and/or K
ccount # Phone ill to Purchase Order # ccount Contact Email ddress OCCIPITL CRDLES WITH HRDWRE Codes: E0955 & E1028 230C 230S 231S 230M 231M 230L 231L Code: E0966-169S Contoured Head & Neck Support...$295.00
[ ] Quote [ ] Order. Junior US Retail Price List. Account Information. Ship To Information. Standard Features.
![[ ] Quote [ ] Order. Junior US Retail Price List. Account Information. Ship To Information. Standard Features.](/thumbs/88/114636031.jpg "[ ] Quote [ ] Order. Junior US Retail Price List. Account Information. Ship To Information. Standard Features.")
Account Information Date Account Number Branch Dealer Contact Phone Fax Email Address PO Number Mark For Ship To Information [ ] Quote [ ] Order Shown with Optional Equipment Standard Features Name Address
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
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
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
R82 Rabbit Up - E0638 / E0642 USD Retail Price List/ Order Form
R82 Rabbit Up - E0638 / E0642 USD 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:
R82 Caribou - E0641. USD Retail Price List/ Order Form. Account #: Purchase Order No.:
Account #: Purchase Order No.: Contact: R82 Caribou - E0641 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
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
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
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:
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
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
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
TiLite Seating System Order Form
Effective October 15th, 2018 (New Items in Red) Page 1 of 5 DEALER INFORMATION RTS INFORMATION Dealer: Account #: RTS: Phone: PO: Ordered By: Email: Email: SHIP TO INFORMATION Mark For: Name: Ship Via:
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.
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 email for a quote. The order form has (MSRP) retail prices, but your price
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
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
Canadian 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
Ride Custom Systems Face Sheet :~)
Ride Designs a branch of Aspen Seating, LLC toll-free 866.781.1633 phone 303.781.1633 fax 303.781.1722 www.ridedesigns.com Ride Custom Systems Face Sheet :~) Please fill in one face sheet per client order.
Back. Ride Custom Back Order Form
Back Client First and Last Name NOTE: This order form must be accompanied by a Ride Custom Seating Systems Face Sheet. Prices effective November 1, 2012. Ride Custom Back (Model #: RCB100) Medicare HCPCS
JAY Fit. Backrest and Seat Assembly. July 2017
JAY Fit Backrest and Seat Assembly July 2017 Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention:
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
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
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
R82 Flamingo Flamingo High-Low
Account #: Purchase Order No.: Contact: R82 Flamingo Flamingo High-Low Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone:
The Churchill. A belt positioning backless booster designed for children and adults lbs with special health care needs
The Churchill A belt positioning backless booster designed for children and adults 65-175 lbs with special health care needs The Churchill must be installed with LATCH (upper tether anchor and lower seat
Quickie IRIS January 2014
Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: ST: ZIP: Address: Dealer Phone: ( ) Fax: ( )
Order Form XL5 and XL5ci manual wheelchair
Order Form XL5 and XL5ci manual wheelchair ate : P.O.#: ccount#: Made for (client) : Ordered by : 2018-08-03 Organization: ddress : FRME OLORS (Visit our website to view colors) Phone : Fax : ONFIRM ORER
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) Freedom 2 Kids
Freedom 2Kids Manual Wheelchair Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Frame Options FD2K Folding Transport Optional (E1236) or (K0005) FD2K-30270 $2085 Note: Transportation
Order Form XL5 and XL5ci manual wheelchair
Order Form XL5 and XL5ci manual wheelchair ate : P.O.#: ccount#: Made for (client) : Ordered by : NIN MSRP 20-11-02 Organization: ddress : Phone : Fax : ONFIRM ORER Y E-MIL Yes No SUSRIE TO PHYSIPRO NEWSLETTER
I C O N hug ski r aft climb shop Ventu
layswimskidanceclimbraceventu ovehugcryrafthikeworkshopea ICON BACK SYSTEM L I F E I S C A L L I N G Icon back system Innovation, Versatility, Comfort For many wheelchair users, a solid back system is
ICON BACK SYSTEM featuring VariLock hardware
LAYHUGLAUGHTRAVELDANCELOVES ORKSIT LIVERELAXEXPERIENCEROLLSHOP ICON BACK SYSTEM featuring VariLock hardware Icon Back System Innovation, Versatility & Comfort For many wheelchair users, a solid back system
Invacare 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:
LOVEHUGCRYRAFTHIKEWORKSHOPEAT
Cushion Composition Shell Composition Hardware Composition A Division of Cascade Designs, Inc. 4000 1st Avenue South Seattle, WA 98134 Phone: (800) 827-4548 Fax: (206) 343-5795 www.varilite.com ICON LOW
R82 Caribou - E0641. Retail Price List/ Order Form. Account #: Purchase Order No.: Date: Caribou Standard Features:
Account #: Purchase Order No.: Date: Contact: R82 Caribou - E0641 Retail Price List/ Order Form Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Caribou
R82 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
Quickie IRIS FSS Net Order Form/Price List (SIN F-1)
Mark For: Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: Dealer Phone: ( ) Fax: ( ) Confirmation Email: Confirm Via: ZIP: Quickie IRIS FSS Net Order Form/Price List (SIN
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
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:
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.
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
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
q Little Wave Flip XP - Rigid Base KF-XPRIGID $
Phone 0800 5 222 Fax 0800 275 65 Effective /06/207 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Little Wave Flip XP - Rigid Base KF-XPRIGID $ 9.8kg weight capacity. One time free
cp 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
HELMET LINERS CONVERSION CHART STOCK HELMET CAN CHANGE HELMET TO: X-Small (6 3/8-6 1/2 ) Small (6 5/8-6 3/4 ) Medium (6 7/8-7 )
One K Helmets boast the perfect synergy between advanced technology and aesthetically pleasing design. With enough features to appeal to those seeking everything a helmet could possibly offer, wrapped
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:
Chair Back Solid. Chair Back. Chair Back. Chair Back
Seats and Backs Seats and Backs Solid Up to 14 x 14... 0625 Up to 18 x 18... 062501 Up to 22 x 22... 062502 I-Modification Up to 14 x 14... 06258 Up to 18 x 18... 062510 Up to 22 x 22... 062511 T-Modification
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
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
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
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:
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
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
Multi-Position Standing(MPS) System US PRICE LIST AND ORDER FORM Effective July 1, 2012
Multi-Position Standing(MPS) System US PRICE LIST AND ORDER FORM Effective July 1, 2012 Date of Order: Dealer Name: Dealer Account #: PO #: Base MFR. PO #: Tag: Purchasing Contact: Phone: Fax: RTS/Therapist:
1 PIECE REAR LIGHT BARS STOP/TURN/TAIL WITH INTEGRATED BACKUP LIGHTS AVAILABLE FOR OVAL AND 4" ROUND LIGHTS
Universal A B WITH 8 STOP / TURN / TAIL LIGHTS (Each) C A. B. C. (8) Round 4 Stop/Turn/Tail Lights (5) 2 Round Lights (2) Super 21 Lights 15404B-01 N15404B-01 (8) Oval Stop/Turn/Tail Lights 15410B-01 N15410B-01
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
$ $ QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE
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:
Alberta AADL Order Form XL5 and XL5ci manual wheelchair
lberta L Order Form XL5 and XL5ci manual wheelchair ate: P.O.#: ccount#: Made for (client): Ordered by: 2018-11-29 Organization: ddress: Phone: Fax: ONFIRM ORER Y E-MIL Yes No SUSRIE TO PHYSIPRO NEWSLETTER
Table of Contents. Order By: Trays. Positioning Straps. Seats and Backs. Bracket Hardware. Electronics. Seating Accessories. Order Forms.
Products Catalog 2012 Table of Contents Richardson Products manufactures and distributes a broad spectrum of rehab and home medical equipment. Our products are manufactured using the highest quality materials
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
OBSS/ Tru Shape Packages
Account Information Date Patient First Name Phone Number Email Address Account Number Last Name Fax Number Primary Contact OBSS/ Tru Shape Packages Order Form Effective Date 09/01/2017 P.O. Number Ship
Photo: Virginie Beauchamp
Product Catalogue 1 2 Photo: Virginie Beauchamp BACKREST (ONE PIECE) Description: Single-piece backrest for upper-body positioning Sturdy aluminium back plate High quality cushion cover 4 mounting points
ACTA-RELIEF LTS ORDER FORM
ACTA-REIEF TS ORDER FORM HCPCS CODING: E2620 POSITIONING BACK, PANAR ITH ATERA SUPPORTS Acta-Relief Patent Pending Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference:
panda futura English manual G B rev. 001
panda futura TM English manual 2004 R82 /S. ll rights reserved. The R82 logo and the Panda Futura chairs are registered trademarks of R82 /S. 02.2008 rev. 001 ontents Safety... 4 uarantee... 4 Seats...
Vector COMFORT-TEK FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE. $ $455.00
VECT LOW & VECT DER FM HCPCS CODING: E2624/E2625 ADJUSTABLE SKIN PROTECTION & POSITIONING Vector Low Vector Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference: Fax:
Kimba Neo. Paediatric postural positioning system. Base price Outdoor mobility base: EUR x,xxx. Base price Seating unit: EUR x,xxx
Base price Outdoor mobility base: EUR x,xxx Base price Seating unit: EUR x,xxx valid from 1/1/2016 to 31/12/2016 Provide estimate only Order Order no.: Kimba Neo Paediatric postural positioning system
ICON Back System. Product Training. Icon Back System
ICON Back System Product Training Innovation Versatility Comfort Simplicity Easy to Use Features and Models Available in 4 models Icon Low Back Icon Mid Back Icon Tall Back Icon Deep Back New design Hardware
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG. Adult Manual Wheelchair
P.R.O. CG Adult Manual Wheelchair TM SE 2241 N Madera Rd Simi Valley, CA 93065 Phone: (800) 331-8551 Fax: (888) 582-1509 www.freedomdesigns.com email: customerservice@freedomdesigns.com Date: Buyer: Company:
PRESCRIPTION FORM. Delivery address. Purchase order. Shipment date Delivery Date. Type
PRESCRIPTION FORM Distributor Branch Client Phone Delivery address (Use 'Shift'+'Enter' for new line) Salesperson E-mail Purchase order Type Date Shipment date Delivery Date Important Demo Request Order
NXT Pediatric. Manual Wheelchair. Transport Optional Base
Pediatric Manual Wheelchair Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Transport Optional Base Folding (E1234) NXT-30300 $2800 Transport Optional Note: Transportation Option selected
Manufacturer: 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
Bio-ST ST & ST-HD. Modifications Removable and/or Additional Foam Shape Contour Covers A A A A & A
Information is provided to: Quote Up-Date a Quote Q Order Quote # Q Purchase Order # Ordered By: Client s Name (Last, First):, Sales Person (RTS): Phone: Fax: E-Mail: Inside Contact: Phone: Fax: E-Mail:
Model # Model # Cushion Extra Outer Cover Width Depth Cushion Extra Outer Cover
MATRX SEATING SERIES Matrx Vi Cushion Matrx Vi Cushions include inner & outer covers. Additional Extra covers are also available. Weight Capacity up to 300 lbs. Fits Wheelchair Cushion Extra Outer Cover
C300 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
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:
TABLE OF CONTENTS PRODUCT COLOR, SIZE, AND CODE LEGENDS LRG + BK CONTENTS. racing shoe size. product size. arm restraints.
17 TABLE OF CONTENTS PRODUCT,, AND CODE LEGENDS CONTENTS GENERAL GEAR RACING HELMETS SIZING CHART RACING SUITS FR UNDERWEAR RACING GLOVES RACING SHOES ACCESSORIES RACING BELTS WINDOW NETS TOWING GEAR 3
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
MEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:
Canada MEDmobility 5711- Calgary Trail NW Edmonton AB T6H 2K1 P: 780-437-3300 F: 780-430-9381 www.medmobility.ca Company: Account Number: Date: Quote PO Number: RTS: AADL #W154 Effective 10/01/2017 Ship
CUSTOM ACTA-BACK DEEP - FULL ORDER FORM HCPCS CODE: E2617
CUSTOM ACTA-BACK DEEP - FU ORDER FORM HCPCS CODE: E2617 CUSTOMER/PATIENT INFORMATION For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving
INDUSTRIES, INC. PRODUCT CATALOG C121
METALCRAFT INDUSTRIES, INC. Note About Digital Catalog Note About Digital Catalog Text In This Digital Catalog That Are Highlighted Are Linked To Other Parts Of The Highlighted Text In This Digital Catalog
Accessories 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
Q6 Edge 2.0 Order Form with TRU-Balance 3 Positioning - Group 3
Q6 Edge 2.0 Order Form with TRU-Balance 3 Positioning - Group 3 Account Number: Date: Provider Name: Contact: Phone: Fax: Email: PO Number: Marked for: Ship to Address: City: State: Zip: INTRODUCTION Thank
QLASS 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:
DME Medical Review Criteria Attachment A2
DME Medical Review Criteria Attachment A2 STRIDEsm (HMO) MEDICARE ADVANTAGE The equipment listed in the following table meets the CMS definition of durable medical equipment (DME) and may be covered if
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
Breg Essentials. Conversion Guide
Breg Essentials Conversion Guide Essential [uh-sen-shuh l] adj. basic, indispensable, or absolutely necessary element Breg Essentials is a new line of orthopedic soft goods designed for everyday patient
Q6 Edge 2.0 Order Form with TRU-Balance 3 Positioning - ODJFS Only
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Q6 Edge 2.0 Order Form with TRU-Balance 3 Positioning - ODJFS Only Account Number:
Q6 Edge Z Order Form with TRU-Balance 3 Positioning - Group 3, ODJFS Only
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 TRU-Balance 3 Positioning - Group 3, ODJFS Only Account
C350 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
For over 30 years, Convaid s core mission has been to provide special needs children, adults, and
Improving lives, one wheelchair at a time... 2013 For over 30 years, Convaid s core mission has been to provide special needs children, adults, and their families with high quality, lightweight, compact-folding