V6 & X8. Table of Contents
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1 V6 & X8 Table of Contents Page 2. Base Page 2. Frame Color Page 3. Seating System Page 3. Reduced Drive Capability Page 4. Power Seat Options: Seat Function Control Page 4. Seat Sizes Page 4. Rehab Seat Back Cane Options Page 5. Rehab Seating Options Page 5. Headrest Options Page 5. Armrest Style Options Page 6. Arm Pads Page 6. Lateral Support Options Page 7. Positioning Options Page 7. Chest Harness Options Page 7 8. Seat Restraint Options Page 8. NonPower Legrest & Footplate Options Page 9. Power Legrest & Footplate Options Page 9. Tires Page 10. Joystick Options Page 10. Joystick Handle Type Page 10. Joystick Mount Page 11. Joystick Accessories Page 11. Alternative Drive System Page 11. Environmental Controls Page 12. Accessories
2 Base Front Wheel Drive Rear Wheel Drive X8 Mid Wheel Drive Hybrid Mid Wheel Drive All Terrain V6 Colors Color X8 Colors Black Red Midnight Black Ocean Blue Mossy Green Fire Engine Red Clover Green Tangerine Realtree 2
3 Seating System: MUST CHOOSE ONE 2799 No Power Seat Frame with Seating System 400 lbs. Capacity Power Tilt In Space* 340 lbs. Capacity ASKIT 135 Integrated Sheer Reduction (IRS) Power Recline for Rehab Seating System* 400 lbs. Capacity Power Recline Multi Positioning Seating System (MPS)* 400 lbs. Capacity LS Variable Seat Height with 12" Seat Elevator for Transfer Assist* 340 lbs. Capacity 2850 Variable Seat Height & Tilt Combination* 340 lbs. Capacity Reduced Drive Capability RDC This option allows for driving capability at 20% speed while elevated and/or tilt. *Must be ordered with upgraded electronics SFCK or MFCK depending on Number of options selected 3
4 Power Seat Options: Seat Function Control MSC5 P S External 5 Button Box Placed Between the Armpad and the Joystick controls modes through button box not throught joystick 3636JS 8 Way Toggle Mounted on the inside or outside of joystick Controls modes through toggle not throught joystick Seat Sizes (Width x Depth) MPS As small as 16" x 16" & as large as 22" x 20" Rehab or Flat Pan As small as 13" x 13" & as large as 23" x 21" Rehab Back Cane Options Picture Coming Soon Picture Coming Soon 1367 Standard Rehab Back Canes 3086 Flip Forward Rehab Back Canes Quick Release for Folding Back Canes Forward 1560 Manual Recline Rehab Back Canes 4
5 Rehab Seating Options CU FN Curve Cushion Molded Foam w/medial & Lateral Thigh Supports 46G Elements Cushion Single Layer Foam w/ Quadra Gel Pack M2 F M2 Cushion Quadra Gel w/ Pelvic, Lateral & Medial Thigh Supports BK M ACTA Back w/ Moldable Center Section & High Resiliency Wings M2 Cushion Quadra Gel w/ Pelvic, Lateral & Medial Thigh Supports BK R Radius Back w/ Hight Resiliency Foam DK V Visco Back w/ High Resiliency Foam Back looks like an ACTA Back Headrest Options 1370 MPS Cloth Headrest MPS Seat Back Only 12x4.5x V MPS Vinyl Headrest MPS Seat Back Only 12x4.5x6.25 HD MF Comfort Company Moldable Headrest Pad 10"wide x 6" heigh *Requires HD BH HD BH Removable Multi Axis Headrest Hardware Depth adj.5" behind backrest to 7" forward Armrest Style Options 1386/87 Standard Removable Armrest attaches to base height adj 2" FUA(1388/89) Flip Up Armrest attaches to base height adj 3" & angle adj PT0031 Reclining Flip Up Armrest attaches to base & seat back height adj 4" & Angle Adj /3073 Cantalever Flip Back Articulating attaches to seat back height 4" & angle adj
6 Arm Pads AP3(1377R/L) 3"x12" Desk Length Oval AP4(1378/79) 4"x16" Tapered Oval GAP LEFT(1381) Trough Style 6" wide x 14", 17" w/hand rest, 22" w/hand rest long GAP RIGHT(1380) Trough Style 6" wide x 14", 17" w/hand rest, 22" w/hand rest long AP75PR Magic Mobility Leatherette Arm Pad 3"x12" Rounded Edges AP7550PR Magic Mobility Leatherette Arm Pad 3"x14" Rounded Edges Lateral Support Options LT1 SA MPS Seating Comfort Company Single Swing Away Lateral Hardware LT1 L/RS4W4T MPS Seating Comfort Company Single Lateral Pad LT1 SA Rehab Seating Comfort Company Single Swing Away Lateral Hardware LT1 RGD Rehab Seating Comfort Company Single Rigid Lateral Hardware LT1 RS4W4T Rehab Seating Comfort Company Single Lateral Pad Rigid, 5"Wx4"T, Stretch Air Cover 6
7 Positioning Options 1509 Removable Hip Guides Set Fixed Hardware, with 4" x 6" Pad Removable Hip Guides Set Fixed Hardware, with 6" x 10" Pad I2010 Removable Knee Adductors set, multi axis, with 4" x 6" Pad Flip Down Knee Adductors set, multi axis, flip down, with 4" x 6" Pad Adductor Cover with Gel Insert RQ30094 Chest Harness Options 1401 Loop Style Positioning Chest Strap 4" x 49.5" SH103M Chest Strap BODYPOINT Monoflex, Rear Pull M 4" x 49.5" PBH Padded Butterfly Positioning Chest Strap 7" at Chest SH331L B1 BODYPOINT Stayflex, Butterfly, Narrow Front Pull L w/o Zipper 3.5" at Chest Seat Restraint Options 1608 Push Button Style Seat Pos. Strap 2"x 64" 1608XL Push Button Style Seat Pos. Strap 2"x 80" ABSB Airline Buckle Seat Pos. Strap 2"x61" EB205L B1/HW312 KIT BODYPOINT Evoflex Pelvic Stabilizer Lg & Mounting Bracker Kit sitting hip Width 14" 18" 7
8 WC19V66 (V6) WC 19 Transit Kit WC19X86(X8) WC 19 Transit Kit Approved According to ANSI/RESNA WC 19 Includes Lap Belt 600mm 2"x32" WC19V67 WC 19 Transit Kit (V6) WC19X87 WC 19 Transit Kit (X8) Approved According to ANSI/RESNA WC 19 Includes Lap Belt 700mm 2"x44" Legrest Options NonPower Legrest & Footplate Options 1347 Center Mount w/1 pc fixed footplate 10" x 13", 10" height adj 1548 Center Mount w/1 pc flip up footplate 10 " x 13", 10" height adj 1355 Center Mount w/2 pc flip up footplate 10" x 13", 10" height adj 1371 Side Mount wleg cane w/2 pc flip up footplate 8.5 " x 6", 13" height adj AMP Swing Away Amputee Support 10" extension right or left 1550 Fixed Center Mount Calf Pads 5.5"x6.5"x1.75 SMCP Swing Away Side Mount Calf Pads For 1371 w/ breathable fabric 2.5" x 8" x 2.5" CS Calf Staps Side Mount Only Length21" 39" Width 4.5" SP102M BODYPOINT Aeromech M 36" Calf Straps Side Mount Only Width 3.5" SP102L BODYPOINT Aeromech L 40" Calf Straps Side Mount Only Width 3.5" R Heel Guard 2" height fits 1347 or A Foot Straps Pair size HL Heel Loops Pair Length 11.5" 8
9 Power Legrest & Footplate Options 1886 Side Mount Power Elevating Swingaway Independent or Combined 2"height adj 1886 CP Side Mount Calf Pads w/ breathable fabric 2.5" x 8" x 2.5" 2232PG Center Mount Power Elevating Articulating CMCP Fixed Center Mount Calf Pads For 223PG 4" x 12" 827A Foot Straps Pair size Standard 2 pc Footplate 5"x10.5" PT 0109 Extra Large 2 pc Footplate May Not Fit w/ all Seat Sizes 5.5"x11.5" PT 0117 Extra Large 2 pc Footplate w/ 2" Heal Guard May Not Fit w/ all Seat Sizes HL Heel Loops Pair Length 11.5" 13" & Width 1" Tires 1575C All Terrain Tire Complete w/ Brushed Aluminum Rim Drive Tires Only 1574 Pneumatic Grey Indoor Hybrid Tire 1573 Solid Grey Indoor Hybrid Tire (Drive Tires Only) 1595 Power Wheelchair Tire Jack 9
10 Joystick Options PG JSM Standard Rnet Joystick Module No LCD Display or Mono Jacks PG JSM509 Color LCD Joystick Display w/monojack Ports for External Switches Joystick Handle Type RJK Cone Shaped Standard 1502 Goal Post 4" PC103B Bodypoint Ball Knob 1/4" ball PC102A BODYPOINT U Shaped w/ Flex Shaft (3" or 4") PC108A BODYPOINT Mushroom Head Rubber Grip Handle (2" or 2.5") Joystick Mount 1490R Standard Fixed Depth Adj 8.25" Right Mount 1490L Standard Fixed Depth Adj 8.25" Left Mount 1500P Swing Away Joystick Swings over 4.5" to the Right 1501P Swing Away Joystick Swings over 4.5" to the Left MM Stealth Midline Mount 2 postiton mount for easy swing away rotation
11 Joystick Accessories PG AM Attendant Control Joystick Mounts to the back of chair or can be hand held TBB Tash Buddy Button Diameter 2.5" & Height.7" Activating Force Outside edge 3.4oz Center 7 oz ESBLK Egg Switch single function push botton that con scroll through modes or profiles CPS9 Swing Away Egg Switch Hardware Stealth Alternative Drive Systems IDH300 1 Stealth i Drive Head Array HDR 4M S C Switch It Head Array Standard 3 Switch Head Array PG CK Chin Control w/ Bib Mount and Adapter SNP Sip and Puff Controls the wheelchair by sipping and puffing PG OMNI Omni Display 4" Color Display for Alternative Drive Systems Environmental Controls PG BTM2 R net Bluetooth Module 2 Joystick controls cell phone or computer 11
12 Accessories 1605 Waterproof Wheelchair Cover 1606 Waterproof Joystick Cover 1603 Medical Necessity Bag Velcro's to Armrest 10.5" x 6" x 1.25" 1604 Deluxe Backpack 13.5" x 15" x 4" Picture Coming Soon PT0052 Cup Holder Self Leveling A02H Articulating Oxygen Holder PT0035 Cane Holder Attaches to 1396 Removable Clear Polycarb the seat back May Not Work w/ Some Table May Not Work w/ Some Options Options 2997(V6) / 2967(X8) Luggage Rack 10.5" x 13" 2855(V6) / 2857(X8) Lighting Kit Mounted on Seat 2 Headlights, 2 Red Marker Lights w/turn Signals PT0029 Set of Mud Guards AT Drive Tires Only PT0036(V6) / PT0037(X8) Lift Brackets Used with 4 Pt Boom Lift PWB Power Buddy Includes USB Charging Port & Reading Light PT0133 Cell Phone Holder Adj. to fit most cell phones WCR630 6' Multifolding Ramp Traction Tape CM Accessory Charger 12 Volt/car outlet & USB Port with a max draw of 6 amps LM100 BeAdaptive Limited Mobility Shooting Mount(for gun or crossbow) TM100 BeAdaptive Trigger Mechanism FM200 Limited Mobility Fishing Mount 12
AT MSRP Price List. Description. HCPCS Code K0020 K0020 K0106 K0106. Part Number AP3 AP4 GAP GAPS 1386/87 FUA PT0031
Client: P.O.#: AT MSRP List AP3 AP4 GAP GAPS 1386/87 FUA PT0031 3 x 12 Desk Length Leatherette 4 x 16 Tapered Leatherette Standard Height Adjustable, Removable Armrest Flip-Up Armrest Left $37.50/ea. $164.00/ea.
The order form has (MSRP) retail prices, but your price is at least 25% less than retail price. Multiply retail by.75 or call or for a quote.
The order form has (MSRP) retail prices, but your price is at least 25% less than retail price. Multiply retail by.75 or call or email for a quote. The order form has (MSRP) retail prices, but your price
Client Information and Specifications:
Model: Frontier V6 Hybrid Rear Wheel Drive 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 260 665 2769 Nov 17 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility
Client Information and Specifications:
Model: Extreme X8 4x4 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 260 665 2769 Jan 18 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility usa.com Bill
Model: V6 Frontier C73 Compact 201 Growth Parkway Angola, IN Phone: Jan 18. Bill To: Dealer: Contact: Address:
Model: V6 Frontier C73 Compact 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 260 665 2769 Jan 18 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility usa.com
Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.
AADL W659/W991 Quantum Q6 Edge Z with TB3 Power Positioning FOR AADL USE ONLY Pride Mobility Products Co. 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Discount:
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Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified
Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.
AADL W592/W991 Quantum Q6 Edge 2.0 with TB3 Power Positioning FOR AADL USE ONLY Pride Mobility Products Co. 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Discount:
Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA Sales: Phone: (866) Fax: (866)
This product is available for purchase online at www.mypride.com Account #: Date: Order No. Fax No. Phone No. PAGE 1 Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Sales: Phone:
M1 - NPO. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
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Canada Quote / Order Form Combi
Canada Quote / Order Form Combi 7105 Northland Terrace Brooklyn Park, MN 55428 Ph# 1-888-538-6872- Ext 2 Fax# 763-582-0442 Amy Jorgensen-Inside Sales AmyJ@danetechnologies.com www.levousa.com Dealer Information
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JIVE M2 SEDEO ERGO... 5 SHROUDS... 5 CHASSIS... 5 COLOURED SHROUD ELEMENTS... 6 BACK... 37
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BENTLEY. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
STELLAR. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
STELLAR. Order Form - USA Prices in U.S. Dollars. January 1, C u s t o m e r a n d O r d e r I n f o r m a t i o n.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
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Quantum 1450 Group 3 Single Power Order Form Up To 600lbs Weight Capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax:
ORDER FORM EIPW25. with CAPTAIN'S SEAT. Print pages 1-10 to exclude pictures. Buyer State Zip
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C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.070118 Shipping Address * * required F r a
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
Quantum Q6400Z Series Group 4 Order Form 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866)
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C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Tag v.070118 Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
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C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.070118 Shipping Address * * required F r a
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Bora. Standard Base Price 4,100. Standard Features SEAT DEPTHS
Power Wheelchair Retail Prescription Form BORAMOD121218 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
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Page 1 of 13 INTRODUCTION PATIENT INFORMATION
Pride Mobility Products Co. For AADL use only 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Email: productorders@pridemobility.com Q6 Edge HD Order Form with TRU-Balance
SHIPPING INFORMATION Provider Acct #:
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Invacare Action 3 NG Transit Retail Max User Weight 125Kg (19.7 stone)
Manual Wheelchair Retail Prescription Form ACTION3NGTRANSIT10112016 Tel: 01656 776222 Fax: 01656 776220 JAN 2017 Email: ordersuk@invacare.co.uk Online Spares available at www.invacare.co.uk Customer Ref:
R82 Stingray - E1233
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Positioning Components Order Form - ODJFS Only
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Quantum 600 Series Group 3 Single Power & Multiple Power Order Form/ODJFS Only 300 lbs. weight capacity. Revised: December 13, 2012 Page 1 of 7
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F3 Corpus. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
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* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
SALSA M. Salsa MWD. Base Price 4,733 STANDARD SEAT: FRAME / SEAT SIZE STANDARD SEAT: CUSHION JAY CUSHIONS JAY COMFORT SEAT
Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: Country: Country: Tel: Fax: Tel: Fax: Order date: Marked for: Purchase order: SALSA M Max. user weight: 140 kg
Standard Base Price : 2,950. Standard Features
Power Wheelchair Retail Prescription Form PRONTOM41PP010716 Tel: 01656 776222 Fax: 01656 776220 JULY 2016 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
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* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
Quantum Rehab A Division of Pride Mobility Products Corporation
Quantum Q600 Group 3 Order Form/ODJFS Only 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866)
Standard Base Price: 618
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Q6 Edge Z Order Form with Contoured and Synergy Seating - Group 3
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SHIPPING INFORMATION Provider Acct #:
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Basic price 2.250,- Excl. VAT
Date Invoice address Invoice address = delivery address Customer code C- Contact person Reference Other delivery address Quote Seat width D64035 35 cm D64040 40 cm D64045 45 cm D64050 50 cm = Standard
x:panda, size 1, med. back X c x:panda, size 1, med. seat 7¼" X c
Account No. Drop Ship: Date: Name P.O. Number: Address Buyer: City Marked For: State Zip E Mail: Tel. Fax Features included in standard price: Height, Depth & Angle Adjustable Back Angle Adjustable Adduction
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* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
Kimba. T h e K i m b a F a m i l y o f P e d i a t r i c M o b i l i t y P r o d u c t s
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Q6 Edge 2.0 Order Form with Pediatric TRU-Balance 3 Positioning - Group 3
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MASS Script Form. Frame. Backrest. Seat Depth
MASS Script Form Company: Account Number: Date: Quote PO Number: RTS: Marked For: Australian Order Order Effective 01/10/2014 Ship To: Address: City: State: Zip: Phone: Email/Fax: Rogue XP K0005, E1235
BEARINGS BEARINGS
TIRES PNEUMATIC.... 1-4 SNAP ON.....4 PRIMO HIGH PERFORMANCE......5-6 SCHWALBE HIGH PERFORMANCE.....5-6 KENDA HIGH PERFORMANCE... 7 MAINTENANCE FREE TIRES SHOX URETHANE TIRES..... 8 URETHANE TIRES....
MASS Script Form. 160 Kg Weight Capacity Charge. Transit Option. 136 Kg maximum weight capacity. Not available with Removable Seat Pan.
MASS Script Form Australian Order Form Effective 05/07/2014 Company: Account Number: Date: Quote PO Number: RTS: Marked For: Ship To: Address: City: State: Zip: Phone: Email/Fax: Catalyst 5Vx K0005 Charge
F5 Corpus. Dealer Information. Client Information. Client Measurements. * Indicates a Required Field. Prices effective: JAN 01, 2018.
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
Options and Accessories
Options and Accessories LIVE WITHOUT LIMITS 2 JAY COMFORT SEATING...4 JAY CLINICAL CUSHIONS AND BACKS...8 POWER SEATING MODULES... 10 BACKREST RECLINE OPTIONS... 12 ARMRESTS... 13 LEGRESTS... 16 Swing
Convaid Trekker 2 - HCPCS E1234 Canadian Retail Price List / Order Form
Account #: Contact: Canadian Retail Price List / Order Form Purchase Order #: Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email: Ship To: Address: City/State/Zip: Phone: TR14 Base Accepts
F5 Corpus VS. Dealer Information. Client Information. Client Measurements. * Indicates a Required Field. * Contact:
* Indicates a Required Field Dealer Information * Contact: Company Code: PERMNZ * Shipping Location: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends
Convaid Trekker 2 - HCPCS E1234 Retail Price List / Order Form
Account #: Contact: Retail Price List / Order Form Purchase Order #: Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email: Ship To: Address: City/State/Zip: Phone: TR14 Base Accepts TR12 & TR14
F5 Corpus VS. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
M3 Corpus. Dealer Information. Client Information. Client Measurements. * Indicates a Required Field. Prices effective: JAN 01, 2018.
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
C350 Corpus 3G. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
Frame Width. Seating Setup. q 16 q 15 q 14 q 17 q 16 q 15 q 14 Short q 18 q 17 q 16 q 15 q 14 q 19 q 18 q 17 q 16 q 15 q 14
Phone 0800 5 Fax 0800 5 365 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Focus CR $ 36kg weight capacity. Tilt range: -5º anterior to 50º posterior. Effective /0/0 Ship To: Address:
Orderform UK / IR Valid from Version 2.1. Alex QLASS. Date:
Alex QLASS 1 / 8 0,8 Dealer: Date: Reference No.: Quantity: Delivery address: 6.948 5.559 Basic configuration Excluding VAT - 4mph/6 km/h RWD - Battery charger 8A -24 V - Armrests standard removable -
Quantum Q1121 Series Group 3 Single Power and Multiple Power Order Form 300 lbs. weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum Q1121 Series Group 3 Single Power and Multiple Power
MASS Script Form. Frame. Backrest. Seat Depth. Tsunami ALX K0005 Charge. Sling Position. Seat Width / Seat Depth. Seat Width.
MASS Script Form Company: Account Number: Date: Quote PO Number: RTS: Marked For: Australian Order Form Effective 05/07/2014 Ship To: Address: City: State: Zip: Phone: Email/Fax: Tsunami ALX K0005 Charge
R82 x:panda. USD Retail Price List/ Order Form. Account #: Purchase Order No.:
Account #: Purchase Order No.: Contact: R82 x:panda USD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US Configuration
q q q q q q q q q q q q q q q q q q Frame q Titanium Frame K5-CAT5-TITAN $ Includes hangers and base frame. Does not include Cross Braces.
Funder: Order Number: Date: q Quote q PO Number: Therapist: Marked For: Catalyst 5 K5-CAT5-ALI 136kg weight capacity Frame Seat Width / Seat Depth Select box corresponding to desired Seat Width and Depth
USA Parts List FUZE T50
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Pride Mobility Products Australia Pty Ltd Apollo Drive Hallam, VIC, 3803 Sales: Phone: (03) Fax: (03)
Quantum MASS 2014 October 2014 Pride Mobility Products Australia Pty Ltd 20-24 Apollo Drive Hallam, VIC, 3803 Sales: Phone: (03) 8770 9600 Fax: (03) 9703 2960 PAGE 1 Account #: Date: Order No. Fax No.
F3 Corpus. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
F3 Corpus. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
SHIPPING INFORMATION Provider Acct #: Address: ST: ZIP:
May 2014 Kids FAST Order Form Maximum Weight Capacity 80 lbs. 12"Wx14.5"Dx19.5"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
ATP MOBILITY ASSESSMENT FORM
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Quantum R4000 Series Group 3 Standard Order Form 300 lbs. weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum R4000 Series Group 3 Order Form 300 lbs. weight capacity
Quantum R4000 Series Group 3 Single Power & Multiple Power Order Form / ODJSF Only 300 lbs weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum R4000 Series Group 3 Single Power & Multiple Power
ULTRA TDX 2. Retail Order Form Max user weight 136kg (21.4 stone) Featuring
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M3 Corpus. Dealer Information. Client Information. Client Measurements
Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified
Spare Parts Catalogue. Version: 2014/10/08b EN
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Invacare Kite (Max Seating System) Retail Max User Weight 160Kg (25 stone)
Power Wheelchair Retail Prescription Form KITEMAX210917 Tel: 01656 776222 Fax: 01656 776220 OCTOBER 2017 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Account No : Contact
Account Number: Provider Name: Contact:
Quantum Rehab Discount: Terms: Freight: Taken By: DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. HCPCS codes should not be considered
4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required MVMA053 MVMA056. MVMA058 English Manual (STD) Dutch Manual
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.450 588-6555 1 866 650-6555 F.450 588-0200 orders@motioncomposites.com www.motioncomposites.com 4.8 MOVE ORDER FORM - INTERNATIONAL P.O.
Sling Position. Push Handle. q Omit Push Handles N/C q Standard Push Handles 53 q Fold Down Push Handles 80 q Bolt-On Push Handles 109
Effective 05/07/2014 Company: Account Number: Date: q Quote q PO Number: RTS: Marked For: q Rogue XP 1825 Rogue Width Grow-able Frame. 275 lb weight capacity. Maximum initial : 16. q Rogue 1495 Rogue Standard
ALEX QLASS. Order form. T: +44 (0) F: +44 (0)
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Quantum 1103 Ultra Series Group 2 Static Seating Order Form 300 lbs. weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum 1103 Ultra Series Group 2 Static Seating Order Form
Specifications are subject to change without notice. 2018, Amylior Inc. (March 2018) AMYSEAT (Rev.0) Page 1 of 7
Page 1 of 7 ACCOUNT INFORMATION P.O. # or Quote: Dealer Contact Name: Email Address: Phone Number: Bill to (Name): Bill to (Location): Ship to (Name): Address: City: State: User Name or Number: User Weight:
For AADL Only AADL Cat. #W558
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LIVE OUT QUICKIE QM-7 LIMITS WITH EXPERIENCE IT ALL. SEDEO Ergo Seating
EXPERIENCE IT ALL The QUICKIE QM-7 with SEDEO Ergo Seating and SpiderTrac 2.0 suspension redefines powered wheelchair technology, inside and out. Travel further, take on new challenges, and be your independent
Account Number: Provider Name: Contact:
Discount: Terms: Freight: Taken By: Quantum Rehab A Division of Pride Mobility Products Corporation 82 Susquehanna Ave., Exeter, PA 8643 Phone: (866)800-2002 Fax: (866) 707-3422 DME providers are responsible
M3 Corpus. Dealer Information. Client Information. Client Measurements
Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified
Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018
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Quantum 1103 Ultra Series Group 2 Single Power Order Form 200 lbs weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum 1103 Ultra Series Group 2 Single Power Order Form