JAY AES - PACKAGE ORDER FORM November 2012

Transcription

1 LOGO JAY AES - PACKAGE ORDER FORM November 2012 Account: QTY Option # QTY Option # SEATING SYSTEMS PACKAGES SEATING SYSTEMS PACKAGES PKG10XX Universal/E-Z Mount Seating Package $1, MOD Stimulite Honeycomb, Seat $ PKG11XX Universal Mount Seating Package $1, MOD Pudgee Foam Partial Insert $ PKG13XX Universal Space-Saver Seating Package $1, MOD1595 5/8 Gel Partial Insert $ PKG20XX Adj J Hook Bracket Seating Package $ MOD1160 Elasto-Gel Addition, Seat $57.25 PKG23XX Ind Adj J Hook Brkt Seating Package $ MOD0050 Omit Foam in Seat $0.00 PKG24XX Ind Adj J Hook Brkt Seating Pkg, Contour $1, MOD HR Foam in Seat $25.20 PKG30XX E-Z Mount Seating Package $ MOD1300 MOD HR Foam in Seat 1 Pudgee Foam in Seat $39.25 $ BASIS SEATING SYSTEM PACKAGES MOD1500 MOD1525 Gel over HR Foam in Seat Cubed Gel over HR Foam in Seat $ $ PKG50XX BASIS Seat/Back pkg $ MOD T-Foam in Seat $79.50 PKG51XX BASIS Seat/Back pkg w/adjustable hinge $ MOD1605 1/2 T-Foam in Seat $45.50 PKG52XX BASIS Seat/Back pkg; contoured $ MOD /2 T-Foam in Seat $96.50 PKG53XX BASIS Seat/Back pkg w/adj hinge; contoured $ MOD T-Foam in Seat $ PKG52XXLK BASIS Seat/Back pkg, Li'l Kiddos $ MOD SunMate Foam in Seat $67.75 PKG53XXLK BASIS Seat/Back pkg contoured, Li'l Kiddos $1, MOD1805 MOD1815 1/2 SunMate Foam in Seat 1-1/2 SunMate Foam in Seat $34.00 $84.75 HARDWARE MOUNTING KITS FOR USE WITH BASIS PACKAGES; PRICED AS KITS MOD1900 MOD SunMate Foam in Seat Incontinent Film Covering $ $76.25 HMK0010 HMK0011 HMK0011T Universal/EZ Mount Universal Universal w\ Transport Option* $ $ $ SEAT MODIFICATIONS STRUCTURAL HMK0020 Adjustable J Hook $ MOD4150 Notches for Back Posts N/C HMK0023 Adjustable Flush Hook $ MOD4175 Mid Seat Cutout for X-Brace $83.75 HMK0030 EZ Mount $ MOD4180 Foam Form Seat $ HMK0040 Li l Kiddos $ MOD4200L Offset Seat, Long on Left side $89.00 HMK0040T Li l Kiddos w\ Transport Option* $ MOD4200R Offset Seat, Long on Right side $89.00 HMK0055 Flush Hook $ MOD4300 MOD4400 T-style Seat Anti-Thrust Seat $94.25 $ SEATING SYSTEM MODIFICATIONS MOD4450 MOD4460 Quick-Fit Anti-Thrust Seat Wedge Seat $ $ MOD1045 Include Adj Offset Hinge, Wide in Pkg $64.75 MOD4500 Cubed Seat (2x2x2 HR foam) $ MOD1055 Include Adj Offset Hinge, Ped in Pkg $64.75 MOD4525 Custom Cubes, Seat $ MOD6800 Transport Option Hardware $ MOD4600 MOD4620 Contour Seat Sculptured Seat $ $ SEAT INSERT PACKAGES MOD4625 Upcharge for Foam Mold, Seat $79.00 SSK10XX Universal/E-Z Mount Seat Package $ SSK20XX Adj J Hook & Rotate Hold Seat Package $ SSK27XX FW Adj J Hook & Rotating Hold seat Pkg $ SSK30XX E-Z Mount Seat Package $ SSK50XX Drop Hook & Rotate Hold Seat Package $ SSK55XX FW Flush Hook & Rotate Hold Pkg $ SSK60XX Drop Hook & Fixed Hold Seat Package $ SSK70XX Li l Kiddos Seat Insert Package $ SSK71XX Li l Kiddos Contour Seat Package $ SEAT MODIFICATIONS - UPHOLSTERY MOD4125 Attaching Strips, Bottom, Hook & Loop $27.50 MOD4126 Attaching Strips, Top, Hook & Loop $27.50 MOD5120 Add Velcro Closure, Custom $ MOD5130 Add Synthetic Sheepskin To Cover, Std $ MOD4630 Quick-Fit Contoured Seat $ MOD4640L Lateral Reinforcement, Seat, Left $86.00 MOD4640R Lateral Reinforcement, Seat, Right $86.00 MOD4650 Substitute ABS for Multi-Ply in Seat $ MOD4655L Belt Strap Notches, Seat, Left $19.00 MOD4655R Belt Strap Notches, Seat, Right $19.00 MOD4700 Built-in Medial Thigh Support $ MOD4725 Contour Lateral Adductor $ MOD4800 Seat Rail Foam Overlay $ MOD4825 Seat - Front Edge Bevel Undercut $ MOD4900 Adjustable Split Seat $ MOD5000 I-style Seat $96.50 MOD5700 Substitute 3/4 Multi-Ply for 1/2 $54.00 MOD8000 Omit T-Nuts N/C MOD9005 Pre-Fit Modification, Seat $79.50 MOD9050 Oversize, over 20 up to 24 $63.50 MOD9075 Oversize, over 24 up to 28 $83.75 MOD5190 Custom Fabric Upcharge, Seat $74.25 MOD9000 Other Custom Seat Modifications QUOTE ADDITIONAL SEAT COVERS COV4100 COV4109 COV4110 Additional Zippered Cover, Flat, Standard Additional Zippered Cover, Custom Additional Slip Over Cover, Flat, Standard $ $ $ Specifications are subject to change without notice. 15 REV.B

2 COV4119 Additional Slip Over Cover, Custom $ Specifications are subject to change without notice. 25 REV.B

3 BACK INSERT PACKAGES BACK MODIFICATIONS - INTERNAL SBK10XX Universal Mount Back Package QUOTE SBK12XX Drop Hook & Fixed Hold (Between) QUOTE SBK20XX Adj J Hook & Fixed/Rotate Hold (Forward) QUOTE SBK21XX Adj J Hook & Fixed Hold (Forward) QUOTE SBK22XX Adj J Hook & Fixed/Rotate Hold (Between) QUOTE SBK23XX Adj J Hook & Fixed Hold (Between) QUOTE SBK24XX Mount Hook & Fixed Hold (Forward) QUOTE SBK25XX E-Z Mount Back Package QUOTE SBK70XX Li l Kiddos Back Package $ SBK71XX Li l Kiddos Contour Back Package $ BACK MODIFICATIONS FOAM MOD0055 Omit Foam in Back N/C MOD Stimulite in Back $ MOD HR Foam in Back $25.50 MOD HR Foam in Back $39.25 MOD Pudgee Foam in Back $ MOD2405 Additional.5 Pudgee Foam in Back $ MOD2500 Gel & HR Foam in Back $ MOD T-Foam in Back $79.50 MOD2605 1/2 T-Foam in Back $46.50 MOD /2 T-Foam in Back $96.50 MOD T-Foam in Back $ MOD SunMate Foam in Back $67.75 MOD2805 1/2 SunMate in Back $34.00 MOD /2 SunMate in Back $84.75 MOD SunMate Foam in Back $ BACK MODIFICATIONS STRUCTURAL MOD4645L Lat Reinforce, Contour/Sculptured; left $86.00 MOD4645R Lat Reinforce, Contour/Sculptured; right $86.00 MOD5180 Foam Form Back $ MOD5200 I-style Back $96.50 MOD5300 T-style Back $96.50 MOD5425 Half-Round Lumbar Roll $ MOD5450 Adj Angle Bi-Angular Back w/ 2 brkts $ MOD5451 Adj Angle Bi-Angular Back w/ 1 brkt $ MOD5460 Adjustable Lumbar Back $ MOD5500 Curved Back $ MOD5501 Curved Back, w/ 2 hinged L Brkts $ MOD5502 Curved Back, w/ 4 Hinged L Brkts $ MOD5525 Rear Upright Foam Overlay $ MOD5530 Curved Foam Addition to Flat Back $ MOD5550 Cubed Back (2x2x2 HR foam) $ MOD5575 Custom Cubes, Back $ MOD5600 Sewn Anterior Positioning Strap Slots $84.75 MOD5650 Substitute ABS for Multi-Ply in Back $ MOD5700 Replace 3/4 Multi-Ply with 1/2 $54.00 MOD5800 Contour Back $ MOD5801 Quick-Fit Contour/Bi-Angular Back $ MOD5802 Quick-Fit Contour Back Only $ MOD5803 Sculptured Back $ MOD5823 Upcharge for Foam Mold, Back $85.00 MOD5850 Scapular Contour Cutout, Back $ MOD8100 Omit T-Nuts, Back N/C MOD9105 Pre-Fit Modification, Back $79.50 MOD9150 Oversize, over 20 up to 24 $63.50 MOD9175 Oversize, over 24 up to 28 $83.75 FTK10XX Thoracic Support Kit, Foam Form, 5H x 5D $ FTK11XX Thoracic Support Kit, Foam Form, 7H x 5D $ FTK12XX Thoracic Support Kit, Foam Form, 9H x 6D $ FTK13XX Thoracic Support Kit, Foam Form, 11H x 7D $ FTK19XX Thoracic Support Kit, Foam Form, Custom $ BACK MODIFICATIONS UPHOLSTERY MOD5125 Add Velcro Closure, Custom $ MOD5135 Add Synthetic Sheepskin To Cover, Std $ MOD5195 Custom Fabric Upcharge, Back $74.25 MOD5610 Shoulder Strap Mounting Grommets $ MOD5620 Attaching Ties for Back, Velcro $20.25 MOD5621 Attaching Ties for Back, Snaps $19.00 MOD5900 Monogram Back, Block N/C MOD5901 Monogram Back, Script N/C MOD9100 Other Custom Modifications, Back $88.00 ADDITIONAL BACK COVERS COV5100 Additional Zippered Cover, Flat, Standard $ COV5109 Additional Zippered Cover, Custom $ COV5110 Additional Slip Over Cover, Flat, Standard $ COV5119 Additional Slip Over Cover, Custom $ LATERAL THORACIC SUPPORT PACKAGES Specify pad size. Order 2 for complete pair. LTK22XX Standard profile bracket $ LTK24XX Med/High profile bracket $ LTK25XX E-Z Access (swing-away) bracket $ LTK30XX E-Z Access and Front Adjust bracket $ LTK35XX Rear Quick Adjust (RQA) bracket $ LTK37XX E-Z Access and RQA bracket $ LTK40XX Reverse Offset Bracket $ LTK45XX Removable Bracket $ LTK47XX Removable & RQA Bracket $ LTK72XX Li l Kiddos standard profile brkt $ LTK75XX Li l Kiddos E-Z Access bracket $ LTK76XX LI l Kiddos Rear Quick Adjust brkt $ LTK77XX Li l Kiddos E-Z Access and RQA brkt $ LATERAL THORACIC SUPPORT MODIFICATIONS MOD2550 1/4 Gel in Thoracic Support $38.25 MOD2650 1/2 T-Foam in Thoracic Support $28.50 MOD2750 1/2 Pudgee in Thoracic Support $38.25 MOD2850 1/2 SunMate in Thoracic Support STANDARD MOD2950 Taper Front Edge of Thoracic Support $14.75 MOD3000 Replace Multi-Ply with ABS $9.50 MOD3100 Add Waterfall Foam to Thoracic Support $39.25 MOD3150 Contour-Fit Pad $49.75 MOD3175 Hinged Pad $ MOD5510 Curved Lateral Pad $16.00 Specifications are subject to change without notice. 35 REV.B

4 LATERAL THORACIC ADDITIONAL HARDWARE AND COVERS MEDIAL THIGH SUPPORT PACKAGES HDW2025 1/4 Bracket Spacer $17.00 HDW2050 1/2 Bracket Spacer $17.00 HDW Height Adapter Plate $25.50 HDW Height Adapter Plate $25.50 HDW Height Adapter Plate $25.50 COV2656 Lateral Bracket Fabric Cover $27.50 LATERAL PELVIC/THIGH SUPPORT PACKAGES LPK22XX LPK27XX Standard profile brkt, pad up to 5Hx18L Removable Brkt, pad up to 5Hx18L $ $ LPK31XX 15º Med/High Profile Brkt, pad up to 5Hx18L $ LPK32XX Med/High Profile brkt, pad up to 5Hx18L $ LPK33XX 20º Adj Removable brkt, pad up to 5Hx18L $ LPK55XX 1 Reverse Offset Brkts, pad up to 5Hx18L $ LPK57XX 20º Adj fixed Brkt, pad up to 5Hx18L $ LPK72XX Li l Kiddos standard profile brkt, pad to 5H x 14L $ LPK76XX Li l Kiddos High Profile Brkt, pad to 5H x 14L $ LPK40XX Lat Pelvic/Thigh Arm Combo w/fixed Brkt $ LPK41XX Lat Pelvic/Thigh Arm Combo w/rem Brkt $ LPK42XX Lat Pelvic/Thigh Arm Combo w/rem, Hgt Adj $ LATERAL PELVIC/THIGH SUPPORT MODIFICATIONS MOD3050 Replace Multi-Ply with ABS $9.50 MOD3055 Contoured Pelvic Supports (Anti-Thrust) $39.25 MOD3550 1/4 Gel in Pelvic Support $38.25 MOD3551 1/4 Gel in Long Pelvic Support $45.50 MOD3650 1/2 T-Foam in Pelvic Support $28.50 MOD3750 1/2 Pudgee in Pelvic Support $41.25 MOD3850 1/2 SunMate in Pelvic Support STANDARD MOD4750L Long, Curved Pad, Pelvic/Thigh left $17.00 MOD4750R Long, Curved Pad, Pelvic/Thigh, right $17.00 ADDITIONAL DISTAL HARDWARE NOTES HDW Distal Ext Adapter Bar $26.50 HDW Distal Ext Adapter Bar $26.50 MTK10XX MTS w/ Swing-Away brkt, 5 or 7 arm $ MTK20XX MTS w/ Swing-Away brkt, 5 or 7, Custom Quote MTK50XX Adj height Swing-Away brkt, 2-3 $ MTK55XX Adj height Swing-Away brkt 2-3, Custom Quote MTK60XX Adj height Swing-Away brkt, $ MTK65XX Adj height Swing-Away brkt, 3-4.5, Custom Quote MTK70XX Adj Hideaway L Mount, $ MTK71XX Adj Hideaway L Mount, 1.5-3, Custom Quote MTK72XX Adj Hideaway T Mount, $ MTK73XX Adj Hideaway T Mount, 1.5-3, Custom Quote MTK74XX Adj Hideaway L Mount, Short $ MTK75XX Adj Hideaway L Mount, Short, Custom Quote MTK76XX Adj Hideaway L Mount, Tall $ MTK77XX Adj Hideaway L Mount, Tall, Custom Quote MTK31XX LK Pull-Away brkt, 1.25 to 2.75 adj $ MKT33XX LK Pull-Away brkt, 1.25 to 2.75 adj, custom QUOTE MTK34XX LK Pull-Away brkt, 2.75 to 4.25 adj $ MTK35XX LK Pull-Away brkt, 2.75 to 4.25 adj, custom Quote MTK93XX Pull-Away brkt, 1.5 to 2 adj $ MTK94XX Pull-Away brkt, 1.5 to 2 adj, Custom Quote MTK95XX Pull-Away brkt, 2 to 3.5 adj $ MTK96XX Pull-Away brkt, 2 to 3.5 adj, Custom Quote MTK97XX Pull-Away brkt, 3.5 to 5.5 adj $ MTK98XX Pull-Away brkt, 3.5 to 5.5 adj, Custom Quote MEDIAL THIGH SUPPORT MODIFICATIONS MOD3555 1/4 Gel in Medial Support $ MOD3655 1/2 T-Foam in Medial Support $28.50 MOD3855 1/2 SunMate Foam in Medial Support STANDARD ANTERIOR PELVIC POSITIONING BELTS SINGLE PULL APB Side Release buckle, Small Pads $56.00 APB Side Release buckle, Med Pads $56.00 APB Push-Button buckle, Small Pads $86.00 APB Push-Button buckle, Med Pads $86.00 APB5115 Li l Kiddos 1 buckle, 4.5 Pads $91.00 APB5116 Li l Kiddos 1 buckle, 5.5 Pads $91.00 APB5117 Li l Kiddos 1 buckle, 7.5 Pads $91.00 ANTERIOR PELVIC POSITIONING BELTS DUAL PULL APB Side Release buckle, Small Pads $56.00 APB Side Release buckle, Med Pads $56.00 APB Push-Button buckle, Small Pads $86.00 APB Push-Button buckle, Med Pads $86.00 APB5125 Li l Kiddos 1 buckle, 4.5 Pads $91.00 APB5126 Li l Kiddos 1 buckle, 5.5 Pads $91.00 APB5127 Li l Kiddos 1 buckle, 7.5 Pads $91.00 ANTERIOR PELVIC POSITIONING BELTS MEDIAL 4-POINT APB Push-Button buckle, Small Pads $ APB Push-Button buckle, Med Pads $ APB Push-Button buckle, Large Pads $ APB5145 Li l Kiddos 1 Push-button buckle, 3.5 Pads $ APB5146 Li l Kiddos 1 Push-button buckle, 4.5 Pads $ Specifications are subject to change without notice. 45 REV.B

5 ANTERIOR TRUNK SUPPORTS CLASSIC STYLE FOOT & ANKLE POSITIONING ATS8100 Dynamic, X-Small $ ATS8101 Dynamic, Small $ ATS8102 Dynamic, Medium $ ATS8103 Dynamic, Large $ ATS8104 Dynamic, X-Large $ ATS8107 Dynamic, Early Intervention $ ATS8300 Structured, X-Small $ ATS8301 Structured, Small $ ATS8302 Structured, Medium $ ATS8303 Structured, Large $ ATS8304 Structured, X-Large $ ANTERIOR TRUNK SUPPORTS CONTOUR STYLE ATS9100 Dynamic, X-Small $ ATS9101 Dynamic, Small $ ATS9102 Dynamic, Medium $ ATS9103 Dynamic, Large $ ATS9104 Dynamic, X-Large $ ATS9107 Dynamic, Early Intervention $ ATS9300 Structured, X-Small $ ATS9301 Structured, Small $ ATS9302 Structured, Medium $ ATS9303 Structured, Large $ ATS9304 Structured, X-Large $ LOWER EXTREMITY POSITIONING KPG10XX Knee Positioning Blocks, + Pullaway Hardware $ KPG19XX Knee Positioning Blocks, Custom + Hardware $ TST7014L Single Leg/Foot Box, Std, 14 W/C (left leg) $ TST7014R Single Leg/Foot Box, Std, 14 W/C (right leg) $ TST7016L Single Leg/Foot Box, Std, 16 W/C (left leg) $ TST7016R Single Leg/Foot Box, Std, 16 W/C (right leg) $ TST7018L Single Leg/Foot Box, Std, 18 W/C (left leg) $ TST7018R Single Leg/Foot Box, Std, 18 W/C (right leg) $ TST7114 Full Width Leg/Ft Box, Std, 14 W/C (1 pc) $ TST7116 Full Width Leg/Ft Box, Std, 16 W/C (1 pc) $ TST7118 Full Width Leg/Ft Box, Std, 18 W/C (1 pc) $ TST6001 Shoe Holder, padded buckles, Small $71.00 TST6101 Shoe Holder, padded buckles, Medium $71.00 TST6201 Shoe Holder, padded buckles, Large $71.00 TST6301 Shoe Holder, padded buckles, Extra-Large $71.00 TST6510L Foot & Ankle Positioner, Small, left $91.00 TST6510R Foot & Ankle Positioner, Small, right $91.00 TST6520L Foot & Ankle Positioner, Medium, left $91.00 TST6520R Foot & Ankle Positioner, Medium, right $91.00 TST6540L Foot & Ankle Positioner, Large, left $91.00 TST6540R Foot & Ankle Positioner, Large, right $91.00 TST6560L Foot & Ankle Positioner, Extra-Large, left $91.00 TST6560R Foot & Ankle Positioner, Extra-Large, right $91.00 UPPER EXTREMITY POSITIONING PRODUCTS CHOOSE: SLOTS NO SLOTS WCT1005 Wooden Support Platform, X-Small $ WCT1000 Wooden Support Platform, Small $ WCT2000 Wooden Support Platform, Medium $ WCT3000 Wooden Support Platform, Large $ WCT4000 Wooden Support Platform, X-Large $ WCT5005 Lexan Support Platform, X-Small $ WCT5000 Lexan Support Platform, Small $ WCT6000 Lexan Support Platform, Medium $ WCT7000 Lexan Support Platform, Large $ WCT8000 Lexan Support Platform, X-Large $ WCT9000 Custom Support Platform $ PLATFORM MOUNTING HARDWARE THW1000 Toggle Hardware $48.00 THW2000 Slide Tube Hardware $ THW3000 Birch Runners $30.00 THW3100 S-style Runners, ABS $30.00 THW3210 Slotted Channel Runners, ABS $34.00 THW3500 Adjustable Lever Mount Hardware $91.00 THW3700 Top Drop Platform $91.00 THW4000 Cam Style Hardware $34.00 THW4500 Angle-Cam Hardware $44.00 PLATFORM ACCESSORIES TAC11XX Platform Padding, Removable Cover $ TAC4100L Joystick Cutout, Left $51.00 TAC4100R Joystick Cutout, Right $51.00 TAC4150 Joystick Midline Cutout $ TAC4175 Platform Cutout, Custom $59.00 THW6000 Strap with Release Buckle $38.00 NOTES Specifications are subject to change without notice. 55 REV.B