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

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1 ccount # Phone ill to Purchase Order # ccount Contact ddress OCCIPITL CRDLES WITH HRDWRE Codes: E0955 & E C 230S 231S 230M 231M 230L 231L Code: E S Contoured Head & Neck Support...$ Small Occipital Cradle Headrest...$ Small Occipital Cradle Headrest w/wire Mesh Insert $ Medium Occipital Cradle Headrest...$ Medium Occipital Cradle Headrest w/wire Mesh Insert $ Large Occipital Cradle Headrest...$ Large Occipital Cradle Headrest w/wire Mesh Insert $ Extension for Positive Locking Multi-xis Headrest Hardware...$ Extension for Positive Locking Multi-xis Headrest Hardware...$ L 8 Extension for Positive Locking Multi-xis Headrest Hardware...$ Extensions vailable for Multi-axis Offset Headrest Hardware Just sk! Seating & Positioning HCPCS Order Form uthorized y Fax # Ship To Date Client Name CONTOURED HED & NECK SUPPORT 230C SMLL 230S E0955 Code: E1028 Select Headrest Mounting Hardware Multi-xis Offset Headrest Hardware Positive Locking Multi-xis Headrest Hardware MEDIUM 230M E0955 Multi-xis Offset Headrest Hardware Positive Locking Multi-xis Headrest Hardware Seating System Mounting racket Seating System Mounting racket LRGE 230L E0955 Codes: E0955 OCCIPITL CRDLES WITHOUT HRDWRE WM WM WM Small Occipital Cradle Headrest Top...$ Small Occipital Cradle Headrest w/wire Mesh Insert Top $ Medium Occipital Cradle Headrest Top...$ Medium Occipital Cradle Headrest w/wire Mesh Insert Top $ Large Occipital Cradle Headrest Top...$ Large Occipital Cradle Headrest w/wire Mesh Insert Top $ Code: E1028 OCCIPITL CRDLE MOUNTING HRDWRE -309M Occipital Cradle Mounting Hdwr. ssm...$ Multi-xis Offset Headrest Hardware 309 Occipital Cradle Mounting Hdwr. ssm......$ Positive Locking Multi-xis Headrest Hardware Multi-xis Offset Headrest Hardware E0955 Positive Locking Multi-xis Headrest Hardware E1028 E1028 1

2 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 N 020S 020Q Solid Seat ase with No Hardware..$ Solid Seat ase with Standard Hardware.$ Solid Seat ase with Quick Release Hardware $ NTI-THRUST SET C D Code/s: E2607 or E2608 and/or K SN nti-thrust Seat ase with No Hardware..$ S nti-thrust Seat ase with Standard Hardware $ SQ nti-thrust Seat ase with Quick Release Hardware...$ WEDGE SET C D Code/s: E2607 or E2608 and/or K SN Wedge Seat ase with No Hardware $ S Wedge Seat ase with Standard Hardware..$ SQ Wedge Seat ase with Quick Release Hardware.$ I-MODIFICTION SET C E D Code/s: E2607 or E2608 and/or K0108 CONTOURED SET 050SN I-Modification Seat ase with No Hardware $ S I-Modification Seat ase with Standard Hardware.$ SQ I-Modification Seat ase with Quick Release Hardware $ C E G I D F H Code/s: E2607 or E2608 and/or K SN Contoured Seat ase with No Hardware $ S Contoured Seat ase with Standard Hardware...$ SQ Contoured Seat ase with Quick Release Hardware..$

3 SETING CONFIGURTION CHRT (center) = ttachment holes for an bducter racket = ttachment holes for Hip Pad rackets and/or Lateral Support rackets QUICK RELESE SETING HRDWRE QRSH Quick Release Seating Hardware...$ STNDRD SETING HRDWRE SH Standard Seating Hardware.$

4 CUSTOM SETING HRDWRE Custom Hardware available upon request. Please sk! 399 Custom Seating Hardware.Quote Only TRYS Code/s: E0950 and/or K T Polycarbonate Tray with lack PVC Rim w/straps 531C Child Size.$ dult Size.$ X X-Wide Size.$ X 2X-Wide Size.$ Fits 12 Wide Chair.$ Fits 14 Wide Chair.$ Fits 16 Wide Chair.$ Fits 18 Wide Chair.$ Polycarbonate Tray Trough Style Hardware.add$ Polycarbonate Tray EZ Lock Clamp Hardware.add$ Polycarbonate Tray with Padding..add$ GEL CUSHIONS High Density Leak Proof Gel Packs with Sunmate Foam Incasement 399 Code: E2609 Custom Gel Cushion..Quote Only HIP PDS H L Code: E XN Hip Pads without Hardware.$75.00/each 656X Hip Pads with Hardware..$112.00/each 4

5 DUCTORS (ll bduction Systems use ¼-20 olts & Nuts) Flip Down bduction System with djustable Pummel H L Code/s: E0957 and E M Flip Down bduction System with djustable Pummel.$ Flip Down bduction System with Depth djustment Code/s: E0957 and E Flip Down bduction System with Depth djustment..$ Regular bduction System with Depth djustment Code/s: E0957 and E Regular bduction System with Depth djustment $ Laterally djustable Regular bduction System with Depth djustment Code/s: E0957 and E Laterally djustable Regular bduction System with Depth djustment... $

6 DUCTORS (cont.) (ll bduction Systems use ¼-20 olts & Nuts) Regular Scissor oard bduction System with Depth djustment 033 Regular Scissor oard bduction System with Depth djustment.. $ Laterally djustable Scissor oard...$ Code/s: E0957 and E1028 DDUCTORS (ll dduction Systems use ¼-20 olts & Nuts) Regular dduction System with Depth djustment 031 Regular dduction System with Depth djustment $ Code/s: E0956 and E1028 Laterally djustable Regular dduction System with Depth djustment 032 Laterally djustable Regular dduction System with Depth djustment $ Code/s: E0956 and E1028 Replacement parts S 067 DUCTOR/DDUCTOR FLEECE COVER...$ S 072 SCISSOR ORD FLEECE COVER...$ S 068 DUCTOR/DDUCTOR DRTEX COVER...$ S 070 SCISSOR ORD DRTEX COVER...$ SPU 102 MED. DUCTOR PD...$

7 POSITIONING CCESSORIES HIP ELTS (ll Hip elts attached using ¼-20 olts, Nuts, and/or T-Nuts) ll positioning belts shown with pads and attach to chair with grommets 651 & 652 Single Closure Hip elts S 025 S Hip elt with Metal uckle No Pad.$ Small 20 Medium 30 Large 40 Custom 2 Hip elt with Metal uckle No Pad.$ Hip elt with Plastic uckle No Pad $ Small 20 Medium 30 Large 40 Custom 600 (not pictured) 4 Point Single Closure Hip elts Hook-n-Loop Closure elt...$ Small 20 Medium 30 Large 40 Custom dd Hip elt Pad...$ & Point Hip elt with Metal uckle No Pad..$ Small 20 Medium 30 Large 40 Custom Point Hip elt with Plastic uckle No Pad.$ Small 20 Medium 30 Large 40 Custom NTERIOR SUPPORTS 337 dd Hip elt Pad $30.00 (ll nterior Supports attached using ¼-20 olts, Nuts, and/or T-Nuts) Chest Straps D-Ring used with Chest Strap Ring Style and 1/2 Pad and each can be made to custom lengths. S 022 S 023 S 037 S 056 S 057 S 058 S 060 Chest Strap Ring Style 4" lack with Velcro 46"..... $ Chest Strap Ring Style 4" lack with Fastex uckle... $ Chest Strap Regular 2" lack with Velcro... $ Chest Strap Ring Style 4" lack Extra Long 58"... $ Chest Strap Ring Style 4" lack Velcro & Shoulder Straps..$ Chest Strap Ring Style 4" Shoulder Straps & Fastex uckle.$ Chest Strap Regular 2" with Side Release uckle...$ S 035 H-Harness.. $ Small 2 x 8 Medium 2 x 9.5 Large 2.5 x X-Large 2.5 x 14 7

8 NTERIOR SUPPORTS (cont.) 4 Point Chest Harnesses Point Chest Harness with Plastic uckles..$ Female Male X-Small Small Medium Large X-Large Point Zipper Chest Harness with Plastic uckles..$ Female Male Small Medium Large Junior Miss Plus Point Front Close Harness with Plastic uckles $ Male Small Medium Large FEMLE MLE VEST MESUREMENTS NO ZIPPER C D E F Male X-Small Male Small Male Medium Male Large Male X-Large Female Small Female Medium Female Large ZIPPER Male Small Male Medium Male Large Female Junior Female Miss Female Plus FITTING RECOMMENDTION CHRT : Shoulder to Seat : rmpit to rmpit Male X-Small 8 to 12 7 to 8 Male Small 12 to 15 8 to 9 Male Medium 16 to 20 9 to 11 Male Large 21 to to 14 Male X-Large 23 to to 14 Female Small 10 to 14 7 to 8 Female Medium 12 to 16 8 to 9 Female Large 17 to 20 9 to 10 Female Junior 16 to 20 9 to 10 Female Miss 21 to to 14 Female Plus 23 to to 16 Note: vest or harness is not a safety device. It is to be used for positioning only and a metal seat belt is required also. 8

9 CK REST PCKGES (ll Packages Shown with Quick Release Hardware) SOLID CK Planar ack Diagram on Page 9 Code/s: E2613 or 2614 and/or K N Solid ack ase with No Hardware.....$ Solid ack ase with Standard Hardware.$ Q Solid ack ase with Quick Release Hardware $ I-NGULR CK C D Code/s: E2613 or 2614 and/or K N i-ngular ack ase with No Hardware $ i-ngular ack ase with Standard Hardware..$ Q i-ngular ack ase with Quick Release Hardware.$ CURVED CK C D Code/s: E2613 or 2614 and/or K N Curved ack ase with No Hardware $ Curved ack ase with Standard Hardware..$ Q Curved ack ase with Quick Release Hardware.$ I-MODIFICTION CK C E D F Code/s: E2613 or 2614 and/or K N I-Modification ack ase with No Hardware $ I-Modification ack ase with Standard Hardware.$ Q I-Modification ack ase with Quick Release Hardware$

10 PLNR CK CONFIGURTION CHRT = ttachment holes for Torso/Lateral Pad rackets T-Nuts C = ttachment holes for an Occipital Head Cradle racket PLNR QUICK RELESE CK HRDWRE QRH Quick Release ack Hardware....$ PLNR STNDRD CK HRDWRE H Standard ack Hardware.$

11 CUSTOM CK HRDWRE Custom Hardware available upon request. Please sk! 399 Custom Seating Hardware.Quote Only PLNR THORCIC SUPPORTS Lateral Pads ack Mounting racket 025 Code: E0956 Fixed Lateral Trunk Supports (pair)..$ Lateral Pads: Small Large Custom: Length Width Depth racket Offset: Custom Offset racket Swing way Lateral Trunk Lateral Pads 307 Code/s: E0956 and E1028 Swing way Lateral Trunk Supports (pair).$ Lateral Pads: Small Large Custom: Length Width Depth racket Offset: Custom S049 Lateral Pad REPLCEMENT COVER...$

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