Kimba Neo. with NUTEC Custom Configured Seating. Order Form. Standard Equipment. USA Fax

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1 Account Information Date Bill To Phone Number Account Number Fax Number Kimba Neo with NUTEC Custom Configured Seating Order Form Effective Date 06/01/2017 Address Buyer P.O. Number Physician/Therapist Ship To Name All specifications and pricing are subject to change without notice Ottobock HealthCare LP _8Z 06/01/2017 Address City State/Zip Code Phone Number Please complete this form and return to Ottobock by fax OR click the button to send via . Order Quote Only Notes: HCPCS Code: E2609 & E2617 & E1234 Standard Equipment Foot-operated positive wheel locks Knob operated tilt-in-space Tension Adjustable Shock absorption Easy Grip and Pull Handles to fold Powder coated scratch resistant frame in black or silver Ball-bearing mounted heavy-duty wheels Swivel front wheels with swivel lock out Ergonomic height-adjustable pushbar Forward or Rear Facing Seat Mount Page 1/9

2 Please read specifications last page to ensure standards and proper fit Client Measurements in inches (must be provided) All patient measurements must be provided. Seating is built off of the patient's dimensions. If this information is provided in wheelchair assessment documents, we will accept copy of this form with order form instead. Measurement in Sitting: Left Right A. Shoulder Width B. Chest Width C. Chest Depth Width (Front Back) D. Hip Width E. Between Knees F. Top of Head G. Occiput ++ Overall width (asymmetrical width for windswept legs or scoliotic posture H. Seat to Top of Shoulder I. Acromium Process (Tip of Shoulder) J. Inferior Angle of Scapula K. Seat to Elbow L. Seat to Iliac Crest M. Upper leg Length (buttocks to back of knee) N. Lower leg Length O. Foot Length Kimba Neo 470G71= E1234 Size 1: 027 silver 350 black 013 white $2, G71= E1234 Size 2: 027 silver 350 black 013 white $2, G71= E1234 Size 2 Kimba base with size 1 seat adapter: 027 silver 350 black 013 white $2, A71=SK175 E1399 Size 2 seat adapter for size 2 Kimba base $ X00=ST007 Transport Tie Downs $51 Page 2/9

3 Upholstery (Attachment Hardware included) 471S71=SK505 K0108 Free Basic Canopy in Black NC 471S71=SK054 K0108 Sun/Rain Canopy,Complete, black/pink $ S71=SK056 K0108 Sun/Rain Canopy,Complete, black/blue $ S71=SK057 K0108 Sun/Rain Canopy,Complete, beige/green $ S71=SK055 K0108 Sun/Rain Canopy,Complete, beige/brown $ S71=SK301 K0108 Sun/Rain Canopy,Complete, grey/black $403 Upholstery Fabric Options (choose Seating System Upholstery) Select Patient Contact Fabric: 194R Reversed Black Dartex 194 Dartex (fabric side up) 195 Black Darlex 201 Black Rubatex 204 Purple Neoprene 023 Spacer Fabric Black 199 Gray Dartexx (smooth) 211 Black Polartec 203 Silver Neoprene Other specify Select Accent Fabric: Vinyls Neoprenes 230 China Green 251 Apple Green Sparkle 204 Violet 248 Fuschia 168 Royal Blue 250 Black Opal Sparkle 202 Blue 226 Marina Blue 206 Navy Blue 167 Teal 223 Ice Pink Cordura 293 Hot pink 118 Tomato Red 374 Digital Camo Other specify Select Lettering: Embroidery Thread Color Block Pink Blue Script White Purple Name/words Black Other specify Select System Size (includes Attachment Hardware, Plywood, Fabrication, TNuts, Basic Foam) 470C49=SS110_S E2609 Kimba basic insert, seat, Size 1 $ C49=SS110_B E2617 Kimba basic insert, back, Size 1 $ C49=SS112_S E2609 Kimba basic insert, seat, Size 2 $ C49=SS112_B E2617 Kimba basic insert, back, Size 2 $ C49=SAR E degree Recline $153 Note: Hip Supports and Armrests should be ordered with basic insert package. Note: Some Technical Specifications may vary due to size of other accessories, e.g. armrest height cannot be less than hip support height +1", if hip supports are ordered. All seats are built equal to patient seat depth and provide 3" of seat depth growth. If patient is within 3" of maximum on page 9, 3" growth may not be possible.hip guides and hardware are considered to achieve this standard. (Hip width must be less than 11" for size 1 Kimba Neo and less than 13" for size 2 Kimba neo) Page 3/9

4 Select Seat Cushion Shape Anti thrust with contour 470C49=CNST $255 or Anti thrust 470C49=ATST $300 or Planar N/C Standard adductors and abductors 1" raise 1.5" thick under pelvis 2.5" thick distal seat 1" run for wedge Standard 1.) >1.5" thick under pelvis 6.) >2.5" thick distal seat 4.) 1" run for wedge 6 (entire rectangular seat 1.5" thick) Select Cushion Type (choose 1) Standard E2609 Basic Cushion - Entire cushion (High density foam ( #5) overlay N/C 470C49=SPB E2609 Skin Protection and Positioning Basic ( T-foam and Sunmate) $ C49=SPM E2609 Skin Protection and Positioning Moderate (#10 Pudgee Foam pelvic well, T Foam Sunmate $ C49=SPA E2609 Skin Protection and Positioning Advanced (action gel pelvic well, Tfoam and Sunmate) $ C49=SPC E2609 Custom, please specify notes section page 1 $400 Seat Modifications 470C49=ASD E2609 Asymmetrical Seat Depth $80 Left Cut back " Right Cut back " 470C49=POM E2609 Pelvic Obliquity Modification (removable foam segments) $119 Finishing Options Seat 470C49=SOL E2609 Incontinence Liners Spray-on $79 470C49=ECM E2609 Covers Extra Cover Modification $77 * Automatically made to fit size of mobility base ordered. 1 Back 470C49=IBM $ Standard Build Patient chest width = #4 Patient Back height = #2 Patient Axilla = top #3 Seat cushion width = #1 Maximum =4" or Rectangular Back N/C Add Lumbar contour velcros to interior foam, adjustable height Standard build #1= seat to shoulder height patient #2 = seat width 470C49=LRF $130 Foam Lumbar Velcro Select Back Cushion Type (choose 1) Standard E2617 Basic Back Entire back cushion 1" high density foam n/c 470C49=BPB E2617 Skin Protection and Positioning Basic ( 1" Sunmate Foam) $ C49=BPM E2617 Skin Protection and Positioning Moderate (1" sunmate foam 1/2" soft T-Foam) $ C49=BPA E2617 Skin Protection and Positioning Advanced (Action Gel, T-Foam, Spinal Relief) $200 Back Modifications (Select shape of back below) 470C49=GBM E2617 Grid Back Modification (Specify grid foam thickness ") $ C49=CURVE E2617 Curved by wood $ C49=CBF E2617 Curved by foam $ C49=BHGB K0108 2" Back Height Growth (incl pad, cover, hardware) $5 470C49=SOL E2617 Incontinence Liners Spray-on (Air Permeable) $79 470C49=RSC E2617 Covers Removable, secondary (top of cover is replaceable) $77 *Automatically made to fit size of mobility base ordered. Page 4/9

5 Accessory Options Lateral Thoracic Supports Minature Hardware Option (when available) Fixed Lateral Thoracic Supports 471C49=LTS-F E0956 Small 3" x 4" Flat Pads Medium 4" x 5" Flat Pads $317 Large 5" x 6" Flat Pads Custom " x " Push Button Swingaway Thoracic Supports Flat Curved 471C49=LTS-PB E0956 Small 3" x 4" Flat Pads Medium 4" x 5" Flat Pads $617 Large 5" x 6" Flat Pads Custom " x " Summer/Winter Thoracic Supports Flat Curved 471C49=LTS-SW E0956 Small 3" x 4" Flat Pads Medium 4" x 5" Flat Pads $569 Large 5" x 6" Flat Pads Custom " x " Summer/Winter Push Button Swingaway Thoracic Supports Flat Curved 471C49=LTS- E0956 Small 3" x 4" Flat Pads Medium 4" x 5" Flat Pads SWPB $685 Large 5" x 6" Flat Pads Custom " x " 471C49=LTS-PC E0956 Hardware and Pad Covers $47 471C49=LTS-HAL E0956 Height Adjustable Lateral Thoracic Supports - (includes mounting track) $144 Mounting Tracks 471C49=TRK-5D K0108 5" Mounting Track Pair $66 471C49=TRK-7D K0108 7" Mounting Track Pair $70 471C49=TRK-9D K0108 9" Mounting Track Pair $70 471C49=TRK-11D K " Mounting Track Pair $77 Lateral Hip & Thigh Supports (Indicate Measurements) Fixed Lateral Hip Supports Height: 3" size 1 seats 4" size 2 seats custom height Pick Which length of lateral hip supports 471C49=LHS-F E0956 Full length of seat $317 3/4 length of seat distal or proximal mount Full length of seat + 3" Match contours of seat Quick Release Hip Supports Height: 3" size 1 seats 4" size 2 seats custom height 471C49=LHS-QR E0956/ E1028 Pick Which length of lateral hip supports Full length of seat 3/4 length of seat distal or proximal mount $594 Full length of seat + 3" Match contours of seat Medial Thigh Supports (Hip Abductor) Slide Out Medial Thigh Support front rear x Length x Height 471C49=ABD-SO E0957 Small 3 2 x Length x Height Medium 3 1/2 2 1/2 x Length x Height $323 Large 4 3 x Length x Height Custom " x " x Length x Height Page 5/9

6 Head Supports (Select Head Support options below) Description Size Concave S, M, L Lateral Control S, M, L 3 Pad Hinged S, M, L Adjustable Concave Headrest S, M, L HCPCS - E0955 & E1028 Pad Multi-Axis Offset AdjustaLock- Flip Down 471C49=HR-MAC 471C49=HR-ALC 471C49=HR-FDC $393 $393 $ C49=HR-MALC 471C49=HR-ALLC 471C49=HR-FDLC $467 $467 $ C49=HR-MA3PH 471C49=HR-AL3PH 471C49=HR-FD3PH $550 $539 $ C49=HR-MAAC 471C49=HR-ALAC 471C49=HR-FDAC $654 $654 $654 Head Support Modifications 471C49=HRM-DYM Dynamic Headrest Modification (available w/adjustarack) $201 Arm Rests (Mounts to Lateral thigh support unless 47C49=MBAR is ordered) Small Pad, 2" x 6" Large Pad, 2 1/4" x 8" Custom Pad " x " 471C49=AR-AH K0019 Adjustable Height Armrests (removable) $536 Armrest Modifications 471C49=MBAR K0019 Bracket Set to mount Armrests without Hip Supports $ C49=AREB K0019 Armrest Pad/ Posterior Elbow Block Pad, specify elbow block height $119 Footrests and Foot Positioning 471C49=FSS E0951 Small Foot Supports 3.75 (w) x 6.25 (d) $ C49=FSM E0951 Medium Foot Supports 4 (w) x 8.25 (d) $ C49=FSL E0951 Large Foot Supports 4 (w) x 9.75 (d) $ C49=KFB K0108 Footplate Build Up $ C49=KFBPAD K0108 Footplate Build Up Pad $ C49=KCP E0951 Calf Strap $30 471C49=KFR1 K0040X2 Single footplate, angle adjustable sz 1 $ C49=KFR2 K0040X2 Individual foot hangers, height and angle adjustable sz 2 $ X00=ST008 K0040 Kimba Neo Angle Adjustable Foot Plate, size 1 $65 471X00=ST009 K0040 Kimba Neo Angle Adjustable Foot Plate, size 2 $65 471B71=ST005 K0108 Slip resistant footrest cover, size 1 $44 471B71=ST105 K0108 Slip resistant footrest cover, size 2 $44 471B71=SK006 K0108 Padding for footrest, size 1 $ B71=SK106 K0108 Padding for footrest, size 2 $125 Positioning Belts 471C49=PB-PHB-M E0978 Hip Belts Padded, Miniature (1" x 42" w/ auto style buckle) $45 471C49=PB-PHB-P E0978 Hip Belts Padded, Pediatric (1 1/2" x 44" w/auto style buckle) $45 471C49=PB-PHB-XS E0978 Two Point Hip Belts Center Pull Padded, Miniature $ C49=PB-PHBS-CP E0978 Two Point Hip Belts Center Pull Padded, Small $ C49=PB-PHBM-CP E0978 Two Point Hip Belts Center Pull Padded, Medium $ C49=PB-PHBL-CP E0978 Two Point Hip Belts Center Pull Padded, Large $ C49=PB-PHBS-DP E0978 Two Point Hip Belts Double Rear Pull Padded, Small $ C49=PB-PHBM-DP E0978 Two Point Hip Belts Double Rear Pull Padded, Medium $ C49=PB-PHBL-DP E0978 Two Point Hip Belts Double Rear Pull Padded, Large $122 Page 6/9

7 Upper Body Positioning Belts 471C49=PB-HBS E0960 H-Belts Padded, Small $ C49=PB-HBM E0960 H-Belts Padded, Medium $ C49=PB-HBL E0960 H-Belts Padded, Large $ C49=PB-DHBS E0960 Dynamic H-Belts Small $ C49=PB-DHBM E0960 Dynamic H-Belts Medium $ C49=PB-DHBL E0960 Dynamic H-Belts Large $ C49=PB-BPSS E0960 Back Pack Straps Small $ C49=PB-BPSM E0960 Back Pack Straps Medium $ C49=PB-BPSL E0960 Back Pack Straps Large $ C49=PB-DBPSS E0960 Dynamic Back Pack Straps Small $ C49=PB-DBPSM E0960 Dynamic Back Pack Straps Medium $ C49=PB-DBPSL E0960 Dynamic Back Pack Straps Large $ C49=PB-BFXS E0960 Butterfly Chest Belts XSmall $ C49=PB-BFS E0960 Butterfly Chest Belts Small $ C49=PB-BFM E0960 Butterfly Chest Belts Medium $ C49=PB-BFL E0960 Butterfly Chest Belts Large $ C49=PB-DBFXS E0960 Dynamic Butterfly Chest Belts XSmall $ C49=PB-DBFS E0960 Dynamic Butterfly Chest Belts Small $ C49=PB-DBFM E0960 Dynamic Butterfly Chest Belts Medium $ C49=PB-DBFL E0960 Dynamic Butterfly Chest Belts Large $ C49=SR-1 K0108 Strap Risers 1" (aluminum) (helps prevent straps from falling off shoulders) $67 Mobility Base Options (all bases in anthracite color) HR E1399 Home Underframe Multi-use therapy base, Size 1 $1,181 HR E1399 Home Underframe Multi-use therapy base, Size 2 $1,181 HR E1399 Twin Tandem accommodates 2 (size 1), seating units, Size 1 $2,714 HR E1238 Cross Kimba outdoor mobility base, Size 1 $2,660 HR E1399 Cross Seat Adaptr, Size 1 $200 HR E1399 Cross Seat Adaptr, Size 2 $200 HR E1399 Cross Swivel Caster Wheel (12") $287 HR E1399 Cross Storage Bag $105 HR E1399 Cross Cycle Trailer $400 Bases 415A89=SK060 E1399 Size 1 Leckey Activity Base with Push Handles $1, A88=SK010 E1399 Size 2 Leckey Activity Base with Push Handles $1, C88=SK110 E1399 Adapter to put Squiggles Seat on size 2 Leckey Activity Base with Push Handles $ A88=SK040 E1399 Mygo Hi-Low Chassis powered (without handle) $3, D89=SK001 Push bar handle (for Squiggles or Mygo) $244 Page 7/9

8 Wheelchair Trays Mounts with Velcro unless ordering with hardware 471C49=KN-WTC1 E0950 size 1 NUTEC Wheelchair Tray 1/4" Clear acrylic $ C49=KN-WTC2 E0950 size 2 NUTEC Wheelchair Tray 1/4" Clear acrylic $ C49=KN-WTB1 E0950 size 1 NUTEC Wheelchair Tray 1/4" ABS $ C49=KN-WTB2 E0950 size 2 NUTEC Wheelchair Tray 1/4" ABS $ C49=TM-RIM E0950 Add 1/2 PVC Rim to Tray $56 Tray Hardware 471C49=KN-WTHW E1028 Standard tray rails/width adjustable/removable $ C49=TM-RS E1028 Retaining strap $23 471C49=TM-TC E1028 Tray Clamps-Toggle $141 Vent Trays and Other Medical Needs Accessories 471S71=ST050 K0108 Medical Necessities Storage bag, brown $ S71=ST052 K0108 Medical Necessities Storage bag, black $ S64=ST005 K0108 Medical Necessities Storage bag, attaches to the push bar $78 471C49=NT-KN-O2H E2208 O2 Tank Holder side mount $ C49=NT-KN-IVP48 E0776 I.V. Pole (for enteral formulas, etc.) $ S71=SK060 E1029 Horizontal tray for vent or misc medical equipment size 1 $ S71=SK160 E1029 Horizontal tray for vent or misc medical equipment size 2 $ C49=NT-KNAT E1029/ E1028 Undercarriage vent tray mount for Respironics Trilogy Vent or misc medical equipment (Does not limit tilt or recline of seat. Will need 90 degree circuit stem for Trilogy unit)* $ C49=NT-KN-LTVM E1029/ E1028 Vent mount for Pulmonetics LTV (vertical vent mount with under carriage platform for battery or misc. May limit tilt and recline)* $ C49=NT-KN- WMTRI E1029/ E1028 Vent mount for Respironics Trilogy (vertical vent mount with under carriage platform for battery or misc. May limit tilt and recline)* $545 * Vent mount interferes with rear facing seat option ** This tray was specifically designed for the LTV model ventilation systems and a nine hour battery with case by Pulmonetic Systems. In order to achieve a 90 seat angle with ventilator battery tray, the seat tilt must be Page 8/9

9 Kimba Technical Specifications: Dimensions and Weights Size 1 Base Size 2 Base MInimum Maximum MInimum Maximum User seat depth* 5 in. 13 in. 8 in. 17 in. User seat width* 5 in. 11 in. 8 in. 13 in. Seat back height* 11 in. 17 in. 11 in. 20 in. Recline Seat tilt 35 Anterior 35 Posterior 35 Anterior 35 Posterior Lateral height adjustment 7 in. 16 in. 7 in. 19 in. Lateral width adjustment 6 in in. 8 in in. Armrest height adjustment in. 9 in in. (15cm) 9 in. Width between frame 15 in in. Weight of frame (without seating system) 23 lbs (10.5kg) 25 lbs (11.5 kg) O2 Holder Inside: in. Outside: 5 in. w X 15 in. h Inside: in. Outside: 5 in. w X 15 in. h Positioning Tray 18 in. w X 16 in. d X 2 in. h (7 in. cut out) 21 in. w X 19 in. d X 2 in. h (7 in. cut out) Shoe Holders in. w X in. d in. w X 7 in. d Load capacity of frame 121 lbs. Front wheel diameter in. Rear wheel diameter 11" Full width 23.6 in. (60cm) 27.5 in. (70cm) Dorsi/Plantar flexion adjustment 10 dorsi flexion to 10 plantar flexion The optional Individual foot hangers with footplate provide maximum dorsi/plantar flexion adjustment and an available /optional inversion eversion Elevating legrest angles Ventilator Tray 13 in. w X 10 in. d X 2 1/2 in. h Kimba Neo Battery Tray 9 1/2 in. w X 6 3/4 in. d X 7 in. h NuTec Battery Tray 11 1/4 in. w X 7 3/4 in. d X 8 in. h Page 9/9