CUSTOM INCEPTION SEAT SUPPORT SURFACE SHORT ORDER FORM

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1 For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then to or print and fax to CUSTOM INCEPTION SEAT SUPPORT SURFACE SORT ORER FORM CPCS COE: E2609 Company Name/ACCT #: P.O. Number: Requested By: Phone: Ship To: Patient Reference: Fax: Contact Customer Support with questions All custom requests should be added in NOTES section on page 4 along with the section number they are in reference to. Requests may require approval. 1 C - C - W Width / epth = $ Base Price Width / epth = $ Base Price Width / epth = $ Base Price Width / epth = $ Base Price *If desired size is not listed above, a 60% up charge will be applied for materials and Customer Support approval is required. 2 COVER MATERIAL OPTIONS COMFORT-TEK provides incontinence protection and is an easily cleaned surface. STRETC-AIR provides air transmission and heat dissipation. GLIEWEAR provides shear reduction and micro-climate control for enhanced skin protection and improved comfort. IAMON & IGI-CAMO are accent fabrics. Care is identical. COMFORT-TEK STANAR IAMON ACCENT (C-COMFORT-TEK) IGI-CAMO ACCENT (C-IGI-COMFORT-TEK) w/ GLIEWEAR $23.00 IAMON ACCENT (C-GW-COMFORT-TEK) IGI-CAMO ACCENT (C-IGI-GW-COMFORT-TEK) STRETC-AIR STANAR IAMON ACCENT (C-STRETC-AIR) IGI-CAMO ACCENT (C-IGI-STRETC-AIR) w/ GLIEWEAR $23.00 IAMON ACCENT (C-GW-STRETC-AIR) IGI-CAMO ACCENT (C-IGI-GW-STRETC-AIR) 3 INCONTINENCE LINER INCONTINENCE LINER $80.00 (C-INCON-LINER) 4 COVER COMFORT-TEK STANAR $83.00 IAMON ACCENT (C-X-COMFORT-TEK) IGI-CAMO ACCENT (C-IGI-X-COMFORT-TEK) w/ GLIEWEAR $ IAMON ACCENT (C-GW-X-COMFORT-TEK) IGI-CAMO ACCENT (C-IGI-GW-X-COMFORT-TEK) STRETC-AIR STANAR $83.00 IAMON ACCENT (C-X-STRETC-AIR) IGI-CAMO ACCENT (C-IGI-X-STRETC-AIR) w/ GLIEWEAR $ IAMON ACCENT (C-GW-X-STRETC-AIR) IGI-CAMO ACCENT (C-IGI-GW-X-STRETC-AIR) 5 SAPE BUIL TO SPECIFICATION (C-SAPE-BUIL-2-SPEC) Build to Specification has no predetermined values. You must continue by selecting any desired features in sections ALL COMMON CUSION SPECIFICATIONS ARE PRE-SELECTE. IF YOU O NOT WIS TO ALTER TESE OPTIONS, YOU O NOT AVE TO MAKE ANY MORE SELECTIONS TROUG TE REST OF TE FORM. OWEVER, YOU MAY MOIFY ALL SPECIFICATIONS IN TEIR RESPECTIVE AREA OF TE ORER FORM. LINEAR (C-SAPE-LINEAR) Base Structure - Flat Bottom ¼ Crosslink Lower Layer - 1 R Medium Middle Layer - ½ R Soft Topper Layer - ½ Viscool Soft ANTI-TRUST (C-SAPE-ANTI-TRUST) Anti-Thrust - 1" (15W and above) ½ seat depth or ½" (14W or below) ZERO ELEVATION CONTOUR (C-SAPE-Z-ELEV-CONTOUR) Straight Adductors - Abductor - ANTI-TRUST CONTOUR (C-SAPE-AT-CONTOUR) Anti-Thrust - 1" (15W and above) ½ seat depth or ½" (14W or below) Straight Adductors - Abductor - 6 BOTTOM FLAT (C-FLAT-BOTTOM) Standard option if no bottom style is selected. ROUN (C-ROUN-BOTTOM) 1/2 to 1 additional profile height will be added. WEGE WEGE STANAR FULL WEGE (C-WEGE-STANAR) STANAR SIE ONLY (C-WEGE-) STANAR SIE ONLY (C-WEGE-) REVERSE FULL WEGE (C-WEGE-REV) REVERSE SIE ONLY (C-WEGE-REV-) REVERSE SIE ONLY (C-WEGE-REV-) WEGE EIGT 1 (C-WEGE-1) 2 (C-WEGE-2) 3 (C-WEGE-3) (C-WEGE-) 1 ½" (15W and above) or 1" (14W or below) 1 ½" (15W and above) or 1" (14W or below) 1 ½" (15W and above) or 1" (14W or below) 1 ½" (15W and above) or 1" (14W or below) 7 ANTI-TRUST A. A. B. Choose one style and a height from directly below your style choice. ANTI-TRUST ANTI-TRUST ANTI-TRUST SIE VIEW STANAR ANTI-TRUST SIE ONLY SIE ONLY EIGT ½ (C-AT-EIGT-0.5) 1 (C-AT-EIGT-1.0) 1½ (C-AT-EIGT-1.5) 2 (C-AT-EIGT-2.0) 2½ (C-AT-EIGT-2.5) (C-AT-EIGT-) ANTI-TRUST WIT GROWT KIT ANTI-TRUST with GROWT KIT SIE VIEW STANAR ANTI-TRUST WIT GROWT KIT (C-AT-STN-GROWT-KIT) Anti-Thrust with (3) 1 strips included for growing the Anti-Thrust depth. Top layer foam is not glued in the seat well allowing access to the 1 pieces. EIGT ½ (C-AT-GK-EIGT-0.5) 1 (C-AT-GK-EIGT-1.0) 1½ (C-AT-GK-EIGT-1.5) 2 (C-AT-GK-EIGT-2.0) 2½ (C-AT-GK-EIGT-2.5) (C-AT-GK-EIGT-) ANTI-TRUST EPT SIE VIEW 4 (C-AT-EPT-4) 5 (C-AT-EPT-5) 6 (C-AT-EPT-6) 7 (C-AT-EPT-7) 8 (C-AT-EPT-8) 9 (C-AT-EPT-9) 10 (C-AT-EPT-10) 11 (C-AT-EPT-11) 12 (C-AT-EPT-12) 13 (C-AT-EPT-13) 14 (C-AT-EPT-14) 15 (C-AT-EPT-15) 16 (C-AT-EPT-16) (C-AT-EPT-) (C-AT-STANAR) (C-AT-) (C-AT-) Notes: Anti-Thrust depth will be half of the seat depth unless otherwise specified. epth dimension is before growth kit strips are applied. C-INCEPTION-SORTFORM REV0518 1/5

2 8 FOAM LAYERS STRUCTURAL LAYER 1/4 CROSSLINK* (C-FOAM-STRUCTURAL-0.25) * Crosslink is not recommended when using a Moldable ATI (Section 19) Viscool and Visco layers must be in 1/2 increments. *** Additional foam layers will be placed on top of the original layer. NOTE: A minimum thickness mid layer must be selected if an ischial modification is selected in Section 9. See Section 9 for details. FOAM RECOMMENATIONS BY USER WEIGT: PEIATRIC or USER <100 lbs. (45 kg) RM RS VIS-M VIS-S VIS-XS VIS-XXS Lower Layer Minimum 1 ½ (lower Mid Layer and mid layer combined) Topper Layer Minimum ¼ STANAR USER 100 to 350 lbs. ( kg) RM RS VIS-M VIS-S VIS-XS VIS-XXS Lower Layer Minimum 1 ½ (lower Mid Layer and mid layer combined) Topper Layer Minimum ¼ BARIATRIC USER >350 lbs. (158 kg) RM RS VIS-M VIS-S VIS-XS VIS-XXS Lower Layer Minimum 3 (lower Mid Layer and mid layer combined) Topper Layer Minimum ½ LOWER LAYER MI LAYER TOPPER LAYER.R. MEIUM.R. MEIUM.R. MEIUM 1/4 ** (C-LOW-RM-0.25) ** 1/4 lower layer is only 1/4 (C-MI-RM-0.25) 1/4 (C-TOP-RM-0.25) 1/2 (C-LOW-RM-0.50) to be used in conjunction 1/2 (C-MI-RM-0.50) 1/2 (C-TOP-RM-0.50) 3/4 (C-LOW-RM-0.75) with 1/4 structural layer. 3/4 (C-MI-RM-0.75) 3/4 (C-TOP-RM-0.75) 1 (C-LOW-RM-1.00) 1 (C-MI-RM-1.00) 1 (C-TOP-RM-1.00) 1 1/4 (C-LOW-RM-1.25) 1 1/4 (C-MI-RM-1.25) 1 1/4 (C-TOP-RM-1.25) (C-LOW-RM-) (3 Max) (C-MI-RM-) (2 Max) (C-TOP-RM-) (2 Max).R. SOFT.R. SOFT.R. SOFT 1/4 (C-LOW-RS-0.25) 1/4 (C-MI-RS-0.25) 1/4 (C-TOP-RS-0.25) 1/2 (C-LOW-RS-0.50) 1/2 (C-MI-RS-0.50) 1/2 (C-TOP-RS-0.50) 3/4 (C-LOW-RS-0.75) 3/4 (C-MI-RS-0.75) 3/4 (C-TOP-RS-0.75) 1 (C-LOW-RS-1.00) 1 (C-MI-RS-1.00) 1 (C-TOP-RS-1.00) 1 1/4 (C-LOW-RS-1.25) 1 1/4 (C-MI-RS-1.25) 1 1/4 (C-TOP-RS-1.25) (C-LOW-RS-) (3 Max) (C-MI-RS-) (2 Max) (C-TOP-RS-) (2 Max) VISCOOL MEIUM $ VISCOOL MEIUM $ VISCOOL MEIUM $ /2 (C-LOW-VIS-M-0.50) 1/2 (C-MI-VIS-M-0.50) 1/2 (C-TOP-VIS-M-0.50) 1 (C-LOW-VIS-M-1.00) 1 (C-MI-VIS-M-1.00) 1 (C-TOP-VIS-M-1.00) (C-LOW-VIS-M-) (3 Max) (C-MI-VIS-M-) (2 Max) (C-TOP-VIS-M-) (2 Max) VISCOOL SOFT $ VISCOOL SOFT $ VISCOOL SOFT $ /2 (C-LOW-VIS-S-0.50) 1/2 (C-MI-VIS-S-0.50) 1/2 (C-TOP-VIS-S-0.50) 1 (C-LOW-VIS-S-1.00) 1 (C-MI-VIS-S-1.00) 1 (C-TOP-VIS-S-1.00) (C-LOW-VIS-S-) (3 Max) (C-MI-VIS-S-) (2 Max) (C-TOP-VIS-S-) (2 Max) VISCOOL SOFT $ VISCOOL SOFT $ VISCOOL SOFT $ /2 (C-LOW-VIS-XS-0.50) 1/2 (C-MI-VIS-XS-0.50) 1/2 (C-TOP-VIS-XS-0.50) 1 (C-LOW-VIS-XS-1.00) 1 (C-MI-VIS-XS-1.00) 1 (C-TOP-VIS-XS-1.00) (C-LOW-VIS-XS-) (3 Max) (C-MI-VIS-XS-) (2 Max) (C-TOP-VIS-XS-) (2 Max) VISCO SOFT $ VISCO SOFT $ VISCO SOFT $ /2 (C-LOW-VIS-XXS-0.50) 1/2 (C-MI-VIS-XXS-0.50) 1/2 (C-TOP-VIS-XXS-0.50) 1 (C-LOW-VIS-XXS-1.00) 1 (C-MI-VIS-XXS-1.00) 1 (C-TOP-VIS-XXS-1.00) (C-LOW-VIS-XXS-) (3 Max) (C-MI-VIS-XXS-) (2 Max) (C-TOP-VIS-XXS-) (2 Max) ***AITIONAL LOWER LAYER (OPTIONAL) ***AITIONAL MI LAYER (OPTIONAL) ***AITIONAL TOPPER LAYER (OPTIONAL).R. MEIUM.R. MEIUM.R. MEIUM 1/4 (C-A-LOW-RM-0.25) 1/4 (C-A-MI-RM-0.25) 1/4 (C-A-TOP-RM-0.25) 1/2 (C-A-LOW-RM-0.50) 1/2 (C-A-MI-RM-0.50) 1/2 (C-A-TOP-RM-0.50) 3/4 (C-A-LOW-RM-0.75) 3/4 (C-A-MI-RM-0.75) 3/4 (C-A-TOP-RM-0.75) 1 (C-A-LOW-RM-1.00) 1 (C-A-MI-RM-1.00) 1 (C-A-TOP-RM-1.00) 1 1/4 (C-A-LOW-RM-1.25) 1 1/4 (C-A-MI-RM-1.25) 1 1/4 (C-A-TOP-RM-1.25) (C-A-LOW-RM-) (3 Max) (C-A-MI-RM-) (2 Max) (C-A-TOP-RM-) (2 Max).R. SOFT.R. SOFT.R. SOFT 1/4 (C-A-LOW-RS-0.25) 1/4 (C-A-MI-RS-0.25) 1/4 (C-A-TOP-RS-0.25) 1/2 (C-A-LOW-RS-0.50) 1/2 (C-A-MI-RS-0.50) 1/2 (C-A-TOP-RS-0.50) 3/4 (C-A-LOW-RS-0.75) 3/4 (C-A-MI-RS-0.75) 3/4 (C-A-TOP-RS-0.75) 1 (C-A-LOW-RS-1.00) 1 (C-A-MI-RS-1.00) 1 (C-A-TOP-RS-1.00) 1 1/4 (C-A-LOW-RS-1.25) 1 1/4 (C-A-MI-RS-1.25) 1 1/4 (C-A-TOP-RS-1.25) (C-A-LOW-RS-) (3 Max) (C-A-MI-RS-) (2 Max) (C-A-TOP-RS-) (2 Max) VISCOOL MEIUM $ VISCOOL MEIUM $ VISCOOL MEIUM $ /2 (C-A-LOW-VIS-M-0.50) 1/2 (C-A-MI-VIS-M-0.50) 1/2 (C-A-TOP-VIS-M-0.50) 1 (C-A-LOW-VIS-M-1.00) 1 (C-A-MI-VIS-M-1.00) 1 (C-A-TOP-VIS-M-1.00) (C-A-LOW-VIS-M-) (3 Max) (C-A-MI-VIS-M-) (2 Max) (C-A-TOP-VIS-M-) (2 Max) VISCOOL SOFT $ VISCOOL SOFT $ VISCOOL SOFT $ /2 (C-A-LOW-VIS-S-0.50) 1/2 (C-A-MI-VIS-S-0.50) 1/2 (C-A-TOP-VIS-S-0.50) 1 (C-A-LOW-VIS-S-1.00) 1 (C-A-MI-VIS-S-1.00) 1 (C-A-TOP-VIS-S-1.00) (C-A-LOW-VIS-S-) (3 Max) (C-A-MI-VIS-S-) (2 Max) (C-A-TOP-VIS-S-) (2 Max) VISCOOL SOFT $ VISCOOL SOFT $ VISCOOL SOFT $ /2 (C-A-LOW-VIS-XS-0.50) 1/2 (C-A-MI-VIS-XS-0.50) 1/2 (C-A-TOP-VIS-XS-0.50) 1 (C-A-LOW-VIS-XS-1.00) 1 (C-A-MI-VIS-XS-1.00) 1 (C-A-TOP-VIS-XS-1.00) (C-A-LOW-VIS-XS-) (3 Max) (C-A-MI-VIS-XS-) (2 Max) (C-A-TOP-VIS-XS-) (2 Max) VISCO SOFT $ VISCO SOFT $ VISCO SOFT $ /2 (C-A-LOW-VIS-XXS-0.50) 1/2 (C-A-MI-VIS-XXS-0.50) 1/2 (C-A-TOP-VIS-XXS-0.50) 1 (C-A-LOW-VIS-XXS-1.00) 1 (C-A-MI-VIS-XXS-1.00) 1 (C-A-TOP-VIS-XXS-1.00) (C-A-LOW-VIS-XXS-) (3 Max) (C-A-MI-VIS-XXS-) (2 Max) (C-A-TOP-VIS-XXS-) (2 Max) C-INCEPTION-SORTFORM REV0518 2/5

3 9 ISCIAL MOIFICATION Only ONE insert may be selected. Ischial inserts are recessed into the mid layer of foam and sit beneath the topper layer. GEL INSERTS 10 AUCTION Select an adductor height AN style for each the left and right side. Front or rear only will be a straight style adductor and be 1/2 the seat support depth or match an anti-thrust depth. 13 ISCIAL RECESS The amount of recess must match the mid layer of foam selected in Section 8, a topper layer must also be selected with this option. Right QUARAGEL INSERT* (C-QUARAGEL) $90.00 Four gel-filled compartments recessed into the mid layer foam in the seat well and through the leg troughs. * ¾ minimum mid layer is required with this insert. ISCIAL GEL INSERT* (C-ISCIAL-GEL) $69.00 Two gel-filled compartments recessed into the mid layer foam in the seat well. * ½ minimum mid layer is required when this insert. ISCIAL MEMORY FOAM INSERT $62.00 Rectangular piece of memory foam which is recessed into the mid layer foam in the seat well. 1 TICK SOFT MEMORY FOAM* (C-ISCIAL-SOFT-1.0) 1 TICK SOFT MEMORY FOAM* (C-ISCIAL-XSOFT-1.0) 1 TICK SOFT MEMORY FOAM* (C-ISCIAL-XXSOFT-1.0) ½ TICK SOFT MEMORY FOAM* (C-ISCIAL-SOFT-0.5) ½ TICK SOFT MEMORY FOAM* (C-ISCIAL-XSOFT-0.5) ½ TICK SOFT MEMORY FOAM* (C-ISCIAL-XXSOFT-0.5) * A mid layer of foam must be selected and, at a minimum, match the selected insert thickness. All custom requests should be added in NOTES section on page 4 along with the section number they are in reference to. AUCTOR REAR SIE AUCTOR EIGT NONE (C--A-NONE) ½ (C--A-0.5) 1 (C--A-1.0) 1½ (C--A-1.5) 2 (C--A-2.0) 2½ (C--A-2.5) (C--A-) TAPERE STRAIGT ONLY SIE AUCTOR EIGT NONE (C--A-NONE) ½ (C--A-0.5) 1 (C--A-1.0) 1½ (C--A-1.5) 2 (C--A-2.0) 2½ (C--A-2.5) (C--A-) TAPERE STRAIGT ONLY 11 ABUCTION REAR VIEW VIEW NONE (C-AB-NONE) ½ (C-AB-EIGT-0.5) 1 (C-AB-EIGT-1.0) 1½ (C-AB-EIGT-1.5) 2 (C-AB-EIGT-2.0) 2½ (C-AB-EIGT-2.5) (C--A-TAPERE) (C-AB-EIGT-) (C--A-STRAIGT) (C--A-REAR-ONLY) (C--A--ONLY) (C--A-TAPERE) (C--A-STRAIGT) (C--A-REAR-ONLY) (C--A--ONLY) 12 COCCYX CUT OUT COCCYX CUT OUT (C-COCCYX-CUT) Cut out will be in the lower layer. AUCTOR Tapered Adductor Straight Adductor Adduction Area ONLY Adduction Area REAR QUARANT RECESS Left Left FULL LENGT RECESS 15 GROWT NOTCES 16 RAIL CUTS Right 14 AMSTRING RELIEF Only ONE option may be selected. Left or right side relief will be half the width of the seat support. FULL WIT RELIEF 1 (C-AM-RELIEF-1) 2 (C-AM-RELIEF-2) (C-AM-RELIEF-) SIE RELIEF 1 (C--AM-RELIEF-1) 2 (C--AM-RELIEF-2) (C--AM-RELIEF-) SIE RELIEF 1 (C--AM-RELIEF-1) 2 (C--AM-RELIEF-2) (C--AM-RELIEF-) 1 (C-GROWT-NOTC-1) 2 (C-GROWT-NOTC-2) 3 (C-GROWT-NOTC-3) (C-GROWT-NOTC-) $ ¼ wide cut will be taken from each side to allow cushion to fit between chair canes. Growth notches may affect adductors in the rear of the seat support. Tip: An Anti-Thrust Growth Kit from Section 7 can be used to adjust the seat well depth also if an anti-thrust feature is needed. 1 (C-RAIL-CUT-1.0) 1½ (C-RAIL-CUT-1.5) 2 (C-RAIL-CUT-2.0) (C-RAIL-CUT-) $ SIE SIE ¼ (C-IR--REAR-0.25) ¼ (C-IR--REAR-0.25) ½ (C-IR--REAR-0.50) ½ (C-IR--REAR-0.50) ¾ (C-IR--REAR-0.75) ¾ (C-IR--REAR-0.75) 1 (C-IR--REAR-1.0) 1 (C-IR--REAR-1.0) 1¼ (C-IR--REAR-1.25) 1¼ (C-IR--REAR-1.25) (C-IR--REAR-) (C-IR--REAR-) $ SIE SIE ¼ (C-IR--FULL-0.25) ¼ (C-IR--FULL-0.25) ½ (C-IR--FULL-0.50) ½ (C-IR--FULL-0.50) ¾ (C-IR--FULL-0.75) ¾ (C-IR--FULL-0.75) 1 (C-IR--FULL-1.0) 1 (C-IR--FULL-1.0) 1¼ (C-IR--FULL-1.25) 1¼ (C-IR--FULL-1.25) (C-IR--FULL-) (C-IR--FULL-) 1½ wide cut will be made along the entire depth of seat support. Rail cuts will affect the amount of cushion left along the sides of especially low-profile seat supports. C-INCEPTION-SORTFORM REV0518 3/5

4 17 LEG LENGT ISCREPENCY The discrepancy reduces the seat depth on the specified side. Standard cut out is half the seat support width. An Offset Leg Length iscrepancy maintains foam abductor shape if built into the seat support or removable abductor centered placement. If offset is selected, the cutout width is reduced by 1½. STANAR ISCREPANCY EPT OFFSET ISCREPANCY EPT SIE SIE ½ (C-LL-EPT-L-0.5) ½ (C-LL-EPT-R-0.5) 1 (C-LL-EPT-L-1.0) 1 (C-LL-EPT-R-1.0) 1½ (C-LL-EPT-L-1.5) 1½ (C-LL-EPT-R-1.5) 2 (C-LL-EPT-L-2.0) 2 (C-LL-EPT-R-2.0) (C-LL-EPT-L-) (C-LL-EPT-R-) SIE SIE ½ (C-LL-O-EPT-L-0.5) ½ (C-LL-O-EPT-R-0.5) 1 (C-LL-O-EPT-L-1.0) 1 (C-LL-O-EPT-R-1.0) 1½ (C-LL-O-EPT-L-1.5) 1½ (C-LL-O-EPT-R-1.5) 2 (C-LL-O-EPT-L-2.0) 2 (C-LL-O-EPT-R-2.0) (C-LL-O-EPT-L-) (C-LL-O-EPT-R-) 18 PLATFORM Accommodates 7/8 or 1 tubing. Two different cross bars are included to accommodate various wheelchair frame types. Fits both folding and non-folding seat rails. Lateral thigh supports can easily be attached. SOLI SEAT PAN (C-RSSP-N-AR) SOLI SEAT PAN W/ STANAR LEG LENGT ISPREPANCY (C-RSSP-STN-LL) SOLI SEAT PAN W/ OFFSET LEG LENGT ISPREPANCY (C-RSSP-OFF-LL) 19 INSERT $ Moldable ATI (Adjustable Technology Insert) enables on-site customization to the contour of the seat support surface. 1/4 Crosslink is not recommended with Moldable ATI and will not be included if a Quick Pick Shape was selected in Section 5. Rigid Insert is 3/16 thick. MOLABLE ATIAJUSTABLE TECNOLOGY INSERT (C-MOLABLE-INSERT) $ RIGI INSERT - GLUE (C-RG-INSERT-GLUE) $84.00 RIGI INSERT - NOT GLUE (C-RG-INSERT-UNGLUE) $ MILITARY BRANC PATC AIR FORCE (C-AIR-FORCE-PATC) ARMY (C-ARMY-PATC) RE (C-RE) PURPLE (C-PURPLE) PINK (C-PINK) MARINES (C-MARINES-PATC) NAVY (C-NAVY-PATC) Patch is added to the cover on each side. Alters appearance only. 21 ZIPPERE POUC ZIPPERE POUC (C-ZIP-POUC) Zippered Pouch is sewn into the front of the seat support cover. 22 COLOR BLUE (C-BLUE) GREEN (C-GREEN) REMOVE (C-REMOVE) Accent colors are applied via colored piping. If no color is selected, our standard silver reflective piping will be used. EN CUSTOM INCEPTION SEAT SUPPORT OPTIONS 23 LATERAL TIG SUPPORT PAS CPCS COE: E0953 You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section A for pad sizes and shapes. In section B, select a cover for each pad selected in section A. L A. BASIC PA & SAPE ZERO ELEVATION *Length (L) refers to the actual size dimension of the support from bottom to top edge. ZERO ELEVATION $52.00 (BL-LPTSP1Z-3L4-L) 3 L X 4 (BL-LPTSP1Z-3L4-R) (BL-LPTSP1Z-3L5-L) 3 L X 5 (BL-LPTSP1Z-3L5-R) (BL-LPTSP1Z-4L4-L) 4 L X 4 (BL-LPTSP1Z-4L4-R) (BL-LPTSP1Z-4L6-L) 4 L X 6 (BL-LPTSP1Z-4L6-R) (BL-LPTSP1Z-4L8-L) 4 L X 8 (BL-LPTSP1Z-4L8-R) (BL-LPTSP1Z-4L10-L) 4 L X 10 (BL-LPTSP1Z-4L10-R) (BL-LPTSP1Z-4L12-L) 4 L X 12 (BL-LPTSP1Z-4L12-R) (BL-LPTSP1Z-4L14-L) 4 L X 14 (BL-LPTSP1Z-4L14-R) (BL-LPTSP1Z-4L16-L) 4 L X 16 (BL-LPTSP1Z-4L16-R) (BL-LPTSP1Z-5L7-L) 5 L X 7 (BL-LPTSP1Z-5L7-R) ANTI-TRUST $52.00 (BL-LPTSP1A-3L4-L) 3 L X 4 (BL-LPTSP1A-3L4-R) (BL-LPTSP1A-3L5-L) 3 L X 5 (BL-LPTSP1A-3L5-R) (BL-LPTSP1A-4L4-L) 4 L X 4 (BL-LPTSP1A-4L4-R) (BL-LPTSP1A-4L6-L) 4 L X 6 (BL-LPTSP1A-4L6-R) (BL-LPTSP1A-4L8-L) 4 L X 8 (BL-LPTSP1A-4L8-R) (BL-LPTSP1A-4L10-L) 4 L X 10 (BL-LPTSP1A-4L10-R) (BL-LPTSP1A-4L12-L) 4 L X 12 (BL-LPTSP1A-4L12-R) (BL-LPTSP1A-4L14-L) 4 L X 14 (BL-LPTSP1A-4L14-R) (BL-LPTSP1A-4L16-L) 4 L X 16 (BL-LPTSP1A-4L16-R) (BL-LPTSP1A-5L7-L) 5 L X 7 (BL-LPTSP1A-5L7-R) B. BASIC PA COVER L ANTI-TRUST COMFORT-TEK (/EA.) LPTS-P1-COMFORT LPTS-P1-COMFORT STRETC-AIR (/EA.) LPTS-P1-STRETC LPTS-P1-STRETC GLIEWEAR ($13.00/EA.) LPTS-P1-GLIE LPTS-P1-GLIE 24 BOILINK LATERAL PELVIC/ TIG SUPPORT ARWARE You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section A, B, -or- C. TT long extention arms (section ) will only work with TT style hardware and GT hardware links (section ) will only work with GT style hardware. A. TT ARWARE, SLOT MOUNT FIXE (BL-LPTS-TT1FXSL1-L) SMALL (BL-LPTS-TT1FXSL1-R) (BL-LPTS-TT1FXSL2-L) MEIUM (BL-LPTS-TT1FXSL2-R) (BL-LPTS-TT1FXSL3-L) LARGE (BL-LPTS-TT1FXSL3-R) REMOVABLE E1028 $ $ (BL-LPTS-TT1RMSL1-L) SMALL (BL-LPTS-TT1RMSL1-R) (BL-LPTS-TT1RMSL2-L) MEIUM (BL-LPTS-TT1RMSL2-R) (BL-LPTS-TT1RMSL3-L) LARGE (BL-LPTS-TT1RMSL3-R) B. TT ARWARE, POWER MOUNT FIXE (BL-LPTS-TT1FXPWL1-L) SMALL (BL-LPTS-TT1FXPWL1-R) (BL-LPTS-TT1FXPWL2-L) MEIUM (BL-LPTS-TT1FXPWL2-R) (BL-LPTS-TT1FXPWL3-L) LARGE (BL-LPTS-TT1FXPWL3-R) $ REMOVABLE E1028 $ (BL-LPTS-TT1RMPWL1-L) SMALL (BL-LPTS-TT1RMPWL1-R) (BL-LPTS-TT1RMPWL2-L) MEIUM (BL-LPTS-TT1RMPWL2-R) (BL-LPTS-TT1RMPWL3-L) LARGE (BL-LPTS-TT1RMPWL3-R) TT ARWARE, POWER MOUNT OPTION NOTE: If choosing the Power Mount ardware, choose the appropriate power mount type to the right. QUANTUM (LPTS-TT1-PW1) PERMOBIL (LPTS-TT1-PW2) QUICKIE (LPTS-TT1-PW3) ROVI (LPTS-TT1-PW4) AVI REAB (LPTS-TT1-PW5) C-INCEPTION-SORTFORM REV0518 4/5

5 BOILINK LATERAL PELVIC/TIG SUPPORT ARWARE CONTINUE C. GT ARWARE, (ONLY SLOT MOUNT) (BL-LPTS-GT2FXS-L) FIXE (BL-LPTS-GT2FXS-R). AITIONAL OPTIONS (BL-LPTS-TT1LARM4) $37.00/ARM (BL-LPTS-TT1LARM4) (BL-LPTS-GT2RMS-L) REMOVABLE E1028 $ (BL-LPTS-GT2RMS-R) *2 additional 1.25 links allowed per hardware ordered. $37.00/LINK EN CUSTOM INCEPTION LATERAL/PELVIC TIG OPTIONS NOTES SUBMIT BY C-INCEPTION-SORTFORM REV0518 5/5