Quickie GTX Swing-Away FSS NET ORDER FORM/PRICE LIST (SIN F-1)

Transcription

1 Account No: Drop Ship/Ship To: Date: Name: P.O. #: Address: Buyer: City: State: Marked For: Zip Code: Phone Number: Seat Depth (Continued) 163SD10 17" NC 163SD11 18" NC 163SD12 19" 1 NC Frame Style 163SD13 E " 1 $ Frame Type K0005 Quickie GTX Swing-Away FSS NET ORDER FORM/PRICE LIST (SIN F-1) Quickie GTX- Swing Away W/C $ FRAME 163FS9 K0005 Standard Frame NC 163SD14 E " 1 $ FS30 Hemi Frame NC 163SD30 E " 1 $ FT23 Standard 250 Lbs. Max Wt Limit NC 163FT58 Heavy Duty Lbs. Max Wt Limit $71.92 *Requires Stabilizer Bar* 1,2,3 Frame Color 163C2 Black NC 163C10 Black Opal NC 163C1 Blue NC 163C38 Blue Opal NC 163C12 Blue Velvet NC 163C36 Candy Blue NC 163C35 Candy Red NC 163C39 Candy Turquoise NC 163C6 Forest Green NC 163C4 Midnight Purple NC Front Seat Height 5 163C37 Orange NC 163SH35 13" NC 163C5 Pearl Pink NC 163SH NC 163C40 Razzleberry NC 163SH41 14" NC 163C11 Toxic Green NC 163SH " NC 163C8 Yellow NC 163SH12 15" NC Custom Colors 163SH " NC 163C43 Mossy Oak Camouflage $ SH14 16" NC 163C42 Stars & Stripes NC 163SH " NC SEATING (See Matrix) EIF3, Effective July 2008 ORDERING INFORMATION PHONE: (800) , FAX: (800) , WEBSITE: QUICKIE GTX SWING AWAY ACCOUNT INFORMATION SEAT WIDTH / SEAT DEPTH MATRIX 163SH16 17" NC 163SH " NC 163SH18 18" NC 163SH " NC Seat Width 163SH21 19" NC Please note: The J3 Back is not available with 12" or 13" frame widths. 163SH " NC 163S3 12" 4 NC 163SH24 20" NC 163S4 13" 4 NC 163SH " NC 163S5 14" NC 163SH27 21" NC 163S6 15" NC 163S7 16" NC 163S8 17" NC FOOTNOTES: 163S9 18" NC 1 Not available with -1" or -2" Back Depth Adjustment 163S10 19" NC 2 Heavy Duty requires Stabilizer Bar 163S11 E " $ Heavy Duty not available with Xtender Power Assist Seat Depth 4 Not available with Jay Precision Backs 163SD5 12" NC 5 Standard Frame Front Seat To Floor Height 16.5"-21" 163SD6 13" NC Hemi Frame Front Seat To Floor Height 13"-18" 163SD7 14" NC 6 Not available with Quickie Xtender, requires Hemi hangers 163SD8 15" NC 163SD9 16" NC PROPER USE OF HCPCS CODES DOES NOT ENSURE COVERAGE OR PAYMENT. FOR COVERAGE INFORMATION, VERIFY THE APPROPRIATE PAYER S COVERAGE POLICY. Specifications are subject to change without notice Sunrise Medical. Quickie GTX Swing Away - Page 1 of Rev. H. -VA 7.09

2 Rear Seat Height 1 Headrest 163RH9 12" NC 163HE1 E0955 Curved Headrest 8" X 4.5" 11 $ RH " NC 163HE2 E0955 Curved Headrest 9" X 4.5" 11 $ RH11 13" NC Back Depth Adjustment 163RH " NC 163BG1 Standard non adjustable NC 163RH13 14" NC 163BG2-1" 12 $ RH " NC 163BG3-2" 12 $ RH15 15" NC HANGER TYPE (MOUNT WITH EXTENSION TUBE) 163RH " NC Hanger 163RH17 16" NC 163H85 60 o Swing In/Out Hanger NC 163RH " NC 163H86 70 o Swing In/Out Hanger NC 163RH19 17" NC 163H87 70 o V Swing In/Out Hanger 13,14, 17 NC 163RH " NC 163H88 70 o Hemi Swing In/Out Hanger NC 163RH20 18" NC 163H24 K0053 Articulating Hanger 14,15,16,17 $ RH " NC 163H14 E0990 Elevating Hanger 14,18,19 $ RH21 19" NC 163H E0990 Hemi Elevating Hanger 14,18,19 $ RH " NC 163H32 Omit Hanger & Footplate -$5.39 Cushion Extension Tube To order any of the following JAY cushions on-chair, please see the on-chair 163E1 Short (See matrix for lengths) NC order form. 163E2 Medium (See matrix for lengths) NC 163JC01 Jay Basic See OF 163E5 Long (See matrix for lengths) NC 163JC02 Jay Easy See OF 163E12 Short ELR (See matrix for lengths) NC 163JC03 Jay Soft Combi P See OF 163E15 Long ELR (See matrix for lengths) NC 163JC04 Jay J2 See OF 163E16 K0037 High Mount 20 $ JC05 Jay J2 DC See OF 163E21 Omit Extension Tube NC 163JC06 Jay Lite See OF Footplate 163SL6 Omit Seat Sling -$ F1 Composite Footplate w/heel Loop 7,20 NC 163CU1 2" Cushion $ F5 ELR Footplate 21 NC XTENDER POWER ASSIST 163F2 K0038 Foam Footplate w/leg Strap $26.97 K0040+ Xtender Power Assist (24" wheels only and 0 camber) 163F3 E0951 Adult Angle Adj. Footplate w/heel Loop $ XT1 E0986 Xtender Power Assist 2,3,4 $2, F48 Platform Flip Up Footplate w/leg Strap $68.32 Xtender Pwr Asst Handrim 163F61 K0040 Locking Angle Adjustable 23 $68.32 f the following torque options) Footplate Options 163XH1 3x Torque Multiplier (Plastic Coated) NC 163HL4 Omit Heel Loop NC 163XH2 1.5x Torque Multiplier (Stainless Steel) NC 163HL6 Omit Leg Strap NC Xtender Pwr Asst Tire Impact Guard 163XW2 E2213 Xtender Airless Tire $ IG20 Neoprene 24 $ XW1 Xtender Pneumatic Tire NC FOOTNOTES: Xtender Pwr Asst Accessories 1 Size Rear STFH Range Size Rear STFH Range 163XA1 Xtndr Spare Nimh Power Pack $ " RW 12"-16.5" 22" RW 13"-17.5" 24" RW 14"-18.5" 24" (559) RW 14.5"-19" (Manual Wheel Add-On Accessory Package for Xtender Only) 26" RW 15"-19.5" 163XA2 24" Spoke Pneu Alum Handrim NC 2 Rear Seat Height Range 17.5"-19.5". Not available with HD Frame 163XA3 24" Spoke Pneu w/airless Alum Hand $ Center Of Gravity Range 1", 0, -.5" 163XA4 24" Spoke Pneu Plastic Handrim $ Not available with Padded S/A Arm 163XA5 24" Spoke Pneu w/airless Plast Hand BACKREST $ Not available with fabric side guards 6 May interfere with some armrest heights Back Type 7 Not available with 12" and 13" seat width 163BT3 Folding Backrest NC 8 Not available with 10"-14" Back Height or Standard Upholstery 163BT1 Non-Folding Backrest NC 9 Stabilizing Bar required with HD Frame Style Backrest Height 10 Only available with Integral Push Handles 163B110 10" To 14" Back Height NC 11 Available only with Folding Stabilizer Bar 163B127 12" To 16" Back Height NC 12 Not available with HD Frame Types or 19"-22" deep seats, Omit Back Upholstery 163B111 14" To 18" Back Height NC 13 Available with 17"-20" frame widths and composite or angle adjustable 163B137 16" To 20" Back Height NC footplates only; 13"-20" widths with foam footplates and platform flip-up Backrest Upholstery 14 Not available with locking angle adjustable footplates or short 163BU1 Standard Upholstery NC extension tubes 163BU8 Adjustable Upholstery 5 $ Only available with composite and adult angle adj footplates 163BU57 Vented Adjustable Upholstery $ Not available with high push wheel locks 163BU14 Omit Back Upholstery -$ Not available with short extension tubes Jay J3 Back Available on 14"-20" frame widths Please see the J3 Back order form for part # s. 19 Only available with aluminum footplates or angle adjustable 163BU34 Jay Precision Back Med w/laterals 6,7 $ Not available with elevating legrest 163BU35 Jay Precision Back Tall w/laterals 6,7 $ Only available with aluminum footplates 163BU41 Jay Precision Back Med w/o Laterals 7 $ Only available with 60 o,70 o or 70 o V hangers and 70 o, 80 o, 163BU42 Jay Precision Back Tall w/o Laterals 7 $ and 90 o direct mount 163KE22 E Lateral Pad Symmetric Swing Away $ Not available below 14" widths and V hangers 163KE20 E0956 Lateral Pad Symmetric $ Only available with 60 o,70 o or 70 o V hangers or hemi hangers 163KE19 E0956 Lateral Pad Asymmetric $ Should additionally be billed as E KE21 E Lateral Pad Asymmetric Swing Away $ Heavy Duty Frames require Integral Push Handles and Stabilizer Bar Backrest Options 27 To order a J3 Back please select Omit Back Upholstery. 163PH6 Integral Push Handles 26 NC Please note: The J3 Back requires back canes or push handles. 163PH5 Fold-Down Push Handles 8 $ PH2 Omit Push Handles NC 163SZ1 Stabilizer Bar 9,10 $ SZ2 Folding Stabilizer Bar 9,10 $ Specifications are subject to change without notice Sunrise Medical. Quickie GTX Swing Away - Page 2 of Rev. H. -VA 7.09

3 Rear Wheel Size Hanger 163RW3 20" Mag Wheel NC 163H89 70 Swing In/Out Front Mount 1 NC 163RW8 22" Mag Wheel NC 163H90 80 Swing In/Out Front Mount 1 NC 163RW1 24" Mag Wheel NC 163H91 90 Swing In/Out Front Mount 1 NC 163RW4 20" Spoke Wheel $ H23 E Elevating (12"-16" Wide Only) $ RW9 22" Spoke Wheel $ H43 E Elevating Hemi (12"-16" Wide Only) $ RW2 24" Spoke Wheel NC 163H32 Omit Hanger -$ RW11 26" Spoke Wheel $21.57 Extensions (Optional) 163RW77 22" Ultra Lightweight Spoke Wheel 14 $ E23 2" 2,3 $ RW78 24" Ultra Lightweight Spoke Wheel 14 $89.90 Footplate Type 163RW80 26" Ultra Lightweight Spoke Wheel 14 $ F4 K0040 Kids Angle Adj. Footplate 12"-16"W $ RW50 24" Mountain Wheel $ F3 K0040 Adult Angle Adj. Footplate $ RW19 24" HT BB Spoke Wheel (559) $ F62 K o Footboard 4,5 $ RW23 24" HT Tnns Spoke Wheel (559) $ F7 Omit Footplate -$ RW26 26" HT BB Spoke Wheel $89.90 ARMREST 163RW22 26" HT Tnns Spoke Wheel $89.90 Armrest- Padded Swing Away 163RW30 24" Spinergy (540) SPOX Black Spokes $ AA16 Padded Swing-Away Adult 6 $ RW42 24" Spinergy (540) SPOX Yellow Spoke $ AA20 Padded Swing-Away Adult Long 6 $ RW43 24" Spinergy (559) SPOX Black Spokes $ AA17 Padded Swing-Away Kids 6 $ RW31 24" Spinergy (559) SPOX White Spokes $ Armrest- Padded Swing Away Hardware 163RW44 26" Spinergy (590) SPOX Black Spokes $ AR6 Standard Hardware NC 163RW24 26" Spinergy (590) SPOX Yellow Spoke $ AR5 Angle Adjustable Hardware $ RW88 24" Spinergy (540) LX Black Spokes $ Armrest- Height Adjustable 163RW89 24" Spinergy (559) LX Black Spokes $ AA8 E0973 Single Post Height Adjustable - Adult 7 $ RW49 Omit Rear Wheel & Axles X-tender 15 NC 163AM1 Desk Length (10") NC FOOTNOTES: 163AM2 Full Length (14") NC 1 Only available with kids angle adjustable, adult angle adjustable 163AA9 E0973 Single Post Height Adjustable - Kids 7 $89.90 or 90 o footboard footplates 163AM1 Desk Length (10") NC 2 Not available with 6" and 7" Casters 163AM2 Full Length (14") NC 3 Not available with 90 o hangers or elevating legrest 163AA86 E Point Height Adjustable 8 $ Only available with 60 o,70 o or 70 o V hangers and 70 o, 80 o, 163AM1 Desk Length NC and 90 o direct mount 163AM2 Full Length CASTERS (See Matrix Page 5) NC 5 Only available up to 16" width Not available with Xtender 163CW1 3" Micro NC 7 Requires minimum axle spacing of 1 1/2"" 163CW30 3" Micro Lighted $ Only available with Adjustable Upholstery (Non Vented) 163CW3 4" Low Profile Polyurethane NC 9 Available only with Frog Legs 163CW31 4" Micro Lighted $ Not available with Frog Legs 163CW47 E2219 4" x 1.5" Semi Pneumatic 9 $ Not available with plastic sideguards 163CW5 5" Low Profile Polyurethane NC 12 Not available with 0 o Camber 163CW51 5" Micro Lighted $ Not available with Xtender Power Assist 163CW6 5" Soft Roll 10 $ Ultra Lightweight Spoke Wheel available with silver anodized 163CW7 E2219 5" x 1.5" Semi Pneumatic $30.56 aluminum handrim and high pressure clincher tire 163CW34 6" Poly NC 15 Only available with Xtender Power Assist 163CW35 E2219 6" x 1.5" Semi Pneumatic $ CW16 7" Poly NC CASTER OPTIONS 163OC1 K0073 Caster Pin Locks 10 $71.92 Caster Suspension 163CF53 E1015 Frog Legs 0# weight to 100# $ CF54 E1015 Frog Legs 101# weight to 190# $ CF55 E1015 Frog Legs 191# weight to 250# $ REAR WHEEL SETUP Axle Spacing HANGER TYPE (DIRECT MOUNT) 163AV7.75" 11,12 NC 163AV2 1" 11,12 NC 163AV3 1.25" 11 NC 163AV3 1.5" NC 163AV8 1.75" NC Camber 163CI1 0 o NC 16317CI 2 o 13 NC 163CI3 4 o 13 NC Rear Wheel & Tire Matrix Wheel Tire Mag Spoke Ultra Light Quickie HT Spinergy Mountain Pneumatic 20,22,24 20,22,24,26 24,26 Pneumatic Airless Insert 20,22,24 20,22,24 24 Mountain Tire 24 Kevlar Latex Tubular 24,26 25 Full Poly Tire 20,22,24 20,22,24 High-Pressure Clincher 22,24,26 22,24,26 24,25,26 Turbo Tread 25,26 Schwalbe Marathon Plus Evol ,25 Kik Mako Black ,25 24 = = = 590 Specifications are subject to change without notice Sunrise Medical. Quickie GTX Swing Away - Page 3 of Rev. H. -VA 7.09

4 Rear Wheel Tire (See Matrix on Page 3) Extension Handle 15 Handrim 163RT1 Pneumatic NC 163EH1 E0961 6" Pair $ RT2 E2213 Pneumatic Airless Insert $ EH2 E0961 6" Right $ RT12 Mountain Tire NC 163EH3 E0961 6" Left $ RT8 Kevlar $34.16 Grade Aid 163RT7 Latex Tubular NC 163GA1 E0974 Grade Aid 10,11,12 $ RT3 Full Poly Tire NC Rear Anti-Tip 163RT6 High-Pressure Clincher $ AT1 E0971 Rear Anti-Tip $ RT5 Turbo Tread NC 163AT53 E0971 Rear Anti-Tip- Swing Away $ RT21 Schwalbe Marathon Plus Evolution $ AT3 Omit Rear Anti-Tip NC 163RT22 Kik Mako Black $28.77 ACCESSORIES Backpack 163HR1 Aluminum Anodized NC 163A1 Black Utility Backpack Open Market 163HR4 Plastic Coated $ A2 Black/Charcoal Kids Open Market 163HR22 Natural Fit Standard Grip 1 $ Seat Pouch 163HR23 Natural Fit Super Grip 1 $ A8 Black Open Market 163HR7 Omit Handrim -$3.60 Spoke Guard 163HR9 8 Vertical Projections 2 $ A23 K0065 Black 13 $ HR8 8 Oblique Projections $ A24 K0065 Clear $ HR11 12 Vertical Projections 2 $70.12 Positioning Belt 163HR10 12 Oblique Projections 2 $ A12 E0978 Belt 2" Aircraft Buckle $30.56 AXLE 163A13 E0978 Belt 2" Aircraft Buckle Padded $41.35 Axle 163A142 E0978 Belt 1-1/2" Auto Buckle Universal $ AX1 Quick Release Steel NC Side Guard 163AX11 Quad Quick Release 3 $ SG1 Fabric Regular 14 $ AX5 Titanium 3, 4 $ SG2 Fabric Kids 14 $ AX16 Titanium Quad 3, 4 $ SG3 Plastic Regular 15 $43.15 Axle Plate 163SG4 Plastic Kids 15 $43.15 C 163AL40 Short $ SG15 Aluminum 15,16 $ C 163AL36 Standard NC 163SG13 Aluminum with Fender 15,16 $ AL37 Amputee $ SG12 Carbon Fiber with Fender 15,16 $ AL39 Xtender NC Miscellaneous 163AL38 Rear Suspension $ A82 Caddy $16.18 REAR SUSPENSION AND CENTER OF GRAVITY 163A87 Travel Wheels 17,18 $44.95 Rear Suspension Weight Rating 163A51 E2207 Crutch Holder 18 $ SV04 From 0# weight to100# NC 163A83 Tool Kit Open Market 163SV05 From 101# weight to190# NC 163A27 Touch Up Paint $ SV06 From 191# weight to 250# NC 163A32 E0950 Wheelchair Tray $89.90 Center of Gravity (CG) Preset 163A54 K0038 Xtra Leg Strap $ CC11-1" NC 163A96 Presta Valve Adapter Open Market 163CC10 -.5" NC FOOTNOTES: 163CC12 0" NC 1 Not available on Quickie HT, Mountain Wheels, or Ultra Lightweight 163CC1.5" NC 2 Only available with Mag or Standard Spoke Wheels 163CC2 1" 5 NC 3 Not available with Spinergy Wheels or Ultra Lightweight Wheels 163CC3 1.5" NC 4 Only available with Performance HT Wheels 163CC4 2" NC 5 Not available with Fixed Short Axle Plate 163CC5 2.5" 8 NC 6 Not available with Standard Axle Plate 163CC6 3" NC 7 Not available with Amputee Axle Plate 163CC7 3.5" 8 NC 8 Not available with Xtender Axle Plate 163CC8 4" 8 NC 9 Not available with Grade Aids or Extension Handles 163CC9 4.5" 5,7,8 NC 10 Not available with Ergo Scissors, Short Throw, or Unilateral Wheel Locks 163CC13 5" 7,8 NC 11 Not available with Unilateral Wheel Lock WHEEL LOCKS AND ANTI-TIPS 12 Not available with polyurethane or high pressure clincher tires Wheel Lock 13 Not available with Spinergy Wheels or Ultra Lightweight Wheels 163WL1 High Mount Push NC 14 Not available with Adjustable or Vented Upholstery 163WL2 High Mount Pull NC 15 Not available with height adjustable or three point ht. adjustable arms 163WL27 Ergo Scissor NC 16 Not available with High Push or Pull Wheel Locks 163WL29 Compact $ Not available with HD Style Frame 163WL24 Unilateral Push Lock- Right 9 $ Not available with Xtender Power Assist 163WL23 Unilateral Push Lock- Left 9 $ WL10 Omit Wheel Lock NC 163WL12 Do Not Mount NC Specifications are subject to change without notice Sunrise Medical. Quickie GTX Swing Away - Page 4 of Rev. H. -VA 7.09

5 Lower Leg Length Matrix Seat Sling To Top Of Footplate Range 60 o Swing In/Out Short Ext 11 3/4-15 1/2 60 o Swing In/Out Med Ext 14 1/ o Swing In/Out Long Ext 16 3/4-20 1/2 60 o Swing In/Out Platform Flip Up Short Ext 11 1/8-15 1/8 60 o Swing In/Out Platform Flip Up Med Ext 13 1/4-17 1/4 60 o Swing In/Out Platform Flip Up Long Ext 15 3/4-19 3/4 70 o Swing In/Out Short Ext 12 1/ o Swing In/Out Med Ext 13 3/4-17 1/2 70 o Swing In/Out Long Ext 16 1/ o Swing In/Out Platform Flip Up Short Ext 12 1/4-15 1/8 70 o Swing In/Out Platform Flip Up Med Ext o Swing In/Out Platform Flip Up Long Ext 16 1/2-19 1/2 70 o "V" Swing In/Out Short Ext 13 1/2-16 1/4 70 o "V" Swing In/Out Med Ext 15 1/2-18 1/4 70 o "V" Swing In/Out Long Ext 17 1/2-20 1/4 70 o "V" In/Out Platform Flip Up Short Ext 12 1/ o "V" In/Out Platform Flip Up Med Ext 14 1/ o "V" In/Out Platform Flip Up Long Ext 16 3/4-19 1/2 70 o Hemi Swing In/Out Short Ext 12 1/ o Hemi Swing In/Out Med Ext /2 70 o Hemi Swing In/Out Long Ext 17 1/ o Hemi In/Out Platform Flip Up Short Ext 13 1/8-15 1/8 70 o Hemi In/Out Platform Flip Up Med Ext 15 1/ o Hemi In/Out Platform Flip Up Long Ext 17 3/4-19 1/2 * All adjustment ranges may vary due to seat height restrictions. * Recommended 2 1/2" footrest clearance to ground surface Caster Size 3" 7" 6" 5" 4" Caster Size 4" 3" 5" 6" 7" * Blank equal not available Front Seat To Floor Height Matrix GTX Swing Away Standard Frame Short Wide Frog Legs Spacer None +.5" +1" None +.5" +1" None +.5" +1" Front Seat Ht 16 1/2 Top * Short, Wide, Spacer set a factory Top 18 Bottom Middle 18 1/2 Bottom Bottom 19 Bottom Bottom 19 1/2 Bottom 17 Top 18 Bottom Top 18 1/2 Bottom Middle 19 Bottom Bottom 19 1/2 Bottom Bottom 20 Bottom 18 Top 18 1/2 Middle 19 Bottom Middle 19 1/2 Bottom Bottom 20 Bottom Bottom 20 1/2 Bottom 18 1/2 19 Middle 19 1/2 Bottom 20 Bottom Bottom 20 1/2 Bottom Bottom 21 Bottom 20 Bottom 20 1/2 Bottom 21 Bottom Short Wide Frog Legs Spacer None +.5" +1" None +.5" +1" None +.5" +1" Front Seat Ht 13 Top 13 1/2 Bottom 14 Bottom 14 1/2 Bottom Top 15 Bottom Middle 15 1/2 Bottom Bottom 16 Bottom 13 1/2 Top 14 Bottom 14 1/2 Bottom 15 Bottom Top 15 1/2 Bottom Middle 16 Bottom Bottom 14 1/2 Top 15 Middle 15 1/2 Bottom 16 Bottom Middle Bottom 15 GTX Swing Away Hemi Frame 15 1/2 Middle 16 Bottom Bottom 18 Bottom Sunrise Medical 7477 E. Dry Creek Pkwy Longmont, CO (800) Specifications are subject to change without notice Sunrise Medical. Quickie GTX Swing Away - Page 5 of Rev. H. -VA 7.09