SHIPPING INFORMATION. Order

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1 Size 3 Order Form MASS 2014 Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Pride Mobility Products Aust Pty Ltd Apollo Drive Hallam VIC 3803 Ph: Fax: Date: Provider Acct #: Provider: Provider Contact: Prov. Address: Provider City: ST: ZIP: Attention: Address: SHIPPING INFORMATION Provider Phone: ( ) Fax: ( ) Ship To City: ST: ZIP: Confirmation Quote Order PO#: Ship To: Address: Ship To Phone: ( ) Fax: ( ) DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. HCPCS codes should not be considered as legal advice. All prices Mark For: MEASUREMENT WORKSHEET Age: Height: ft. in. ROCK Size 3 chair, Tilt-in-Space Includes: Tilt in space, dynamic, mobility base, Silver metallic frame color, standard configuration. Weight: lbs. K E1161 ROCK Chair - Size 3 A. Sitting Depth B. Trunk Depth C. Trunk Width D. Hip Width E. Top of Shoulder to Seat Figure 1 - Client Measurements F. Lower Leg Length Transit Option Seating System and Back System Required for WC19 Occupied Status.Transit Option must be factory installed and is not retrofitable Transit Option Call for "back canes only" special transit configurations. Reaction Dynamic Seating - Std Requires Angle Adjustable Leg Rests Upholstery Color KRC302 E2295 REACTION Dynamic Component Upper Body Spring Selections C Soft - Pair N/C C Medium - Pair C Hard - Pair N/C Upholstery Color applies to: back cushions lateral pelvic/thigh supports 306 Black/Sport Mesh 311 Vibrant Red/Black/Sport Mesh N/C 309 Purple/Black/Sport Mesh N/C 310 Teal/Black/Sport Mesh N/C Front Rigging Required with REACTION Dynamic Seating System E0990 Angle Adjustable Leg Rest Required when ordering KRC302 Active Seating Accessory. Knee angle adj. 18 incr. w/press of button. allows active movement of lower leg. Lower Body Spring Selections C Soft - Pair N/C C Medium - Pair C Hard - Pair N/C Page 1 of 6

2 Foot Plate Requires Front Rigging Selection Fixed Foot Plate N/C K0040 Quick Angle Adj. Flip-Up Foot Plate -18 to +45 Dorsal/Plantar Flexion. 8 Positions. ROCK 3 Adjustable Depth Seating System K " Adj. Depth Seat Pan Kids UP LifeForm Contoured Seat Cushion Selections Seat Cushions Incl: 2 Positioning Wedges, Abductor Wedge; Black Mesh Cover Ischial Insert Selection Required E " Width, 14-17" Depth C (14") Open Cell Foam E " Width, 14"-17" Depth C (17") E " Width, 17"- 20" Depth C (14") C (17") K0108 Soft Memory Foam C (14") C (17") K0108 Medium Memory Foam Kids UP LifeForm Seating System Accessories Extra Positioning Wedges (4) Wedge for Seat Cushion Pressure Relief Layer - Soft (14" x 8" x 1") Memory Foam (17" x 20" x 1/2") Wedge for Seat Cushion (17" x 9" x 1") Synergy Seat Cushion Options CUSASMB1190 E2607 Synergy Solution Cushion 14"x12" CUSASMB1004 E2607 Synergy Solution Cushion 14"x14" CUSASMB1005 E2607 Synergy Solution Cushion 14"x16" CUSASMB1006 E2607 Synergy Solution Cushion 14"x18" CUSASMB1007 E2607 Synergy Solution Cushion 16"x16" CUSASMB1966 E2607 Synergy Solution Cushion 16"x17" CUSASMB1008 E2607 Synergy Solution Cushion 16"x18" CUSASMB1967 E2607 Synergy Solution Cushion 16"x19" CUSASMB1009 E2607 Synergy Solution Cushion 16"x20" CUSASMB1968 E2607 Synergy Solution Cushion 17"x16" CUSASMB1248 E2607 Synergy Solution Cushion 17"x17" CUSASMB1969 E2607 Synergy Solution Cushion 17"x18" CUSASMB1249 E2607 Synergy Solution Cushion 17"x19" CUSASMB1970 E2607 Synergy Solution Cushion 17"x20" CUSASMB1801 E2603 Synergy Solution 1 Seat Cushion 14"x14" W/Gel Layer CUSASMB1802 E2603 Synergy Solution 1 Seat Cushion 14"x16" W/Gel Layer CUSASMB1803 E2603 Synergy Solution 1 Seat Cushion 14"x18" W/Gel Layer CUSASMB1804 E2603 Synergy Solution 1 Seat Cushion 16"x16" W/Gel Layer CUSASMB1805 E2603 Synergy Solution 1 Seat Cushion 16"x18" W/Gel Layer CUSASMB1806 E2603 Synergy Solution 1 Seat Cushion 16"x20" W/Gel Layer CUSASMB1807 E2603 Synergy Solution 1 Seat Cushion 17"x17" W/Gel Layer CUSASMB1808 E2603 Synergy Solution 1 Seat Cushion 17"x19" W/Gel Layer Pride Mobility Produccts. ROCK3 REV. 11/2013 Page 2 of 6

3 ROCK 3 Back System Options E2293 Configurable, Contoured, Adjustable Height Solid I-Back System Kids UP Lifeform Back Cushion Options Select 1 if is Selected. Back Cushions include contouring wedges and lumbar support C 18"-23" Contoured Back Cushion. (I-Back) C 22"-26"" Contoured Back Cushion. (I-Back) C Basic Fixed Height Armrest 12" Thin Profile - Pair Armrest Options E0973 Adjustable Height Armrest Thin Profile Pad - Pair E0950 Upper Extremity Positioning Platform Color - Clear Tray - incl clear tray & h/ware E0950 Upper Extremity Positioning Platform Color - Gray Angle/Depth Adj. Support Hardware - Req. for all trays ROCK 3 Padded Tray Cover Rear Wheel Options X0D18C 18" Composite Rear Wheels X0D24C 24 Composite Rear Wheels. Requires angle adjust system Rear Tire Options X Full Polyurethane w/treads Page 3 of 6

4 Rear Anti-Tips E0971 Rear Anti-Tips with Wheels (Pair) Hand Rims Axle Plate for 24" Wheels Required DXXC Chrome Hand Rims N/C Adj. Position Axle System DXXC Plastic Coated Hand Rim Casters C 8" x 2" Poly Casters N/C Lateral Pelvic/Thigh Supports L E0956 Left Pelvic/Thigh Support Pkg R E0956 Right Pelvic/Thigh Support Pkg. Lifeform Anterior Pelvic Positioning Belts Medial 4-point pelvic positioning belt recommended with REACTION seating. Positioning belts not for use as a occupant restraint during transit in a motor vehicle E0978 LifeForm 2-point 1" Metal PB Buckle, 3.5" pads E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 3.5" pads E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 4.5" pads E0978 LifeForm 2-point 1.5" Metal PB Buckle, 6.5" pads E0978 LifeForm Medial 4-point 1.5" Metal PB Buckle, 6.5" pads Lifeform Anterior Trunk Support Anterior Trunk Supports not for use as a occupant restraint during transit in a motor vehicle. LifeForm Zipper Opening Dynamic E0960 Zipper Opening - S E0960 Zipper Opening - M E0960 Zipper Opening - L LifeForm Zipper Opening Structured E0960 Structured Zipper Opening - S E0960 Structured Zipper Opening - M E0960 Structured Zipper Opening - L Lifeform Swing-Away Abductor Hardware and Pads 4-way stretch cover included with Lifeform Abductor pads E1028 ROCK 3 S/A Abduct. Hardware E0957 Small Wedge(2"-3"W x 4"L x 3"D) Page 4 of E0955 Med. Wedge (2"-4.5" x 5"L x 3"D) E0955 Lg. Wedge (3"-5" x 5"L x 4"D)

5 Lifeform Headrest and Support Hardware - choose pad size incl h/ware E0955 8" Curved Oval Pad E1028 LifeForm Removable Headrest E " Curved Oval Pad Mounting Hardware (Required for all Headrest Options) E " Curved Oval Pad * Universal Head Rest Mount Plate Only* E0955 Narrow Adjustable Arc Pad E0955 Standard Adjustable Arc Pad *Accomodates several other manufacturers headrests. Call for details. Lifeform Ankle and Foot Positioning - choose type & size LifeForm Hard Side Foot Stabilizers - LifeForm Ankle Hugger Foot Stabilizers - N/C L K0108 Left - Medium - 4"W L K0108 Left - Medium - 4"W R K0108 Right - Medium - 4"W R K0108 Right - Medium - 4"W L K0108 Left - Large - 5"W L K0108 Left - Large - 5"W R K0108 Right - Large - 5"W R K0108 Right - Large - 5"W Lifeform Swing Away Lateral Support Hardware - choose brkt style & pad type & size Choose your bracket and CURVED pad size Choose your bracket and PLANAR pad size L E0956 Left 1.5" pediatric bracket lateral thoracic support package, L E0956 Left 1.5" pediatric bracket lateral thoracic support package, Planar Pad R E0956 Right 1.5" pediatric bracket R E0956 Right 1.5" pediatric bracket Planar Pad L E0956 Left 2" bracket lateral thoracic support package, L E0956 Left 2" bracket lateral thoracic support package, Planar Pad R E0956 Right 2" bracket lateral thoracic support package, R E0956 Right 2" bracket lateral thoracic support package, Planar Pad Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose Swing-Away Hardware (required) Choose Swing-Away Hardware (required) Requires , 3120, 3210, Requires , 3120, 3210, L E1028 Left 1.5" DoubleSwing R E1028 Right 1.5" DoubleSwing L E1028 Left 2" DoubleSwing R E1028 Right 2" DoubleSwing L E1028 Left 1.5" DoubleSwing R E1028 Right 1.5" DoubleSwing L E1028 Left 2" DoubleSwing R E1028 Right 2" DoubleSwing LifeForm 1.5"Swing-Away Width and Depth Ext.(optional) Options Available only with Swing-Away Hardware L Depth Ext. + 1", pediatric, Left N/C L Depth Ext. + 1", 2" Brkt., Left N/C R Depth Ext. + 1", pediatric, Right N/C R Depth Ext. + 1", 2" Brkt., Right N/C L Width Ext. + 1", pediatric, Left N/C L Width Ext. + 1", 2" Brkt., Left N/C R Width Ext. + 1", pediatric, Right N/C R Page 5 of 6 LifeForm 2"Swing-Away Width and Depth Ext.(optional) Options Available only with Swing-Away Hardware. Width Ext. + 1", 2" Brkt., Right N/C

6 Choose your bracket and CURVED pad size L E0956 Left 1.5" fixed pediatric bracket LifeForm Fixed Lateral Support Hardware Choose your bracket and PLANAR pad size L E0956 Left 1.5" fixed pediatric bracket Planar Pad R E0956 Right 1.5" fixed pediatric bracket R E0956 Right 1.5" fixed pediatric bracket Planar Pad L E0956 Left 2" fixed bracket lateral thoracic support package, L E0956 Left 2" fixed bracket lateral thoracic support package, Planar Pad R E0956 Right 2" fixed bracket lateral thoracic support package, R E0956 Right 2" fixed bracket lateral thoracic support package, Planar Pad Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Accessories Life Support Accessories NOT tested with Transit. Must remove prior to tie down K0105 IV Support Pole E E2208 Oxygen Tank Holder E1029 Ventilator Tray for LTV Ventilator Series Only Requires 18" Rear Wheels Battery/Vent. Accessory Tray Requires 18" Rear Wheels (Does not include vent. mount for LTV) Underchair Cargo Tray (carries up to 10lbs) Rock 3 Sunshade Replacement Contoured Seat Cushion Covers E "w x 17"d Seat Cushion Cover Only E "w x 17"d Seat Cushion Cover Only E "w x 20"d Seat Cushion Cover Only Custom Notes: Additional Extras R R R R R R Upper Body - Soft - Pair Replacement Springs Upper Body - Med - Pair Upper Body - Hard - Pair Lower Body - Soft - Pair Lower Body - Med - Pair Lower Body - Hard - Pair Page 6 of 6

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