SHIPPING INFORMATION Provider Acct #: Address: ST: ZIP:
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1 May 2014 Kids FAST Order Form Maximum Weight Capacity 80 lbs. 12"Wx14.5"Dx19.5"H Seating Capacity. Customer Service: (toll free) Date: Quote Order SHIPPING INFORMATION Provider Acct #: PO#: Provider: Ship To: Provider Contact: Attention: Prov. Address: Address: Provider City: ST: ZIP: Address: Provider Phone: ( ) Fax: ( ) Ship To City: ST: ZIP: Ship To Phone: ( ) Fax: ( ) Confirmation 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 MEASUREMENT WORKSHEET Mark for: Age: in. Height: ft. Weight: lbs. Includes: Adjustable Positioning Shell; Folding Tilt Mobility Base; Quick Release 12" Rear Wheels, 8" Casters; Sunshade, Rear Storage Bag; Frame Color: Silver Metallic (002) Kids FAST Chair, Tilt-in-Space. E1234 Transit Option Back Systems or Required to meet ISO Standard ROCK /FAST Chair - Size 1 Transit Option Crash Tested to ISO Standard $2, $ Upholstery Color Upholstery Color applies to: back; cushions; lateral pelvic/thigh supports; rear storage bag; sunshade; calf protector. Does not apply to reverse Dartex. Vibrant Red/Gray/Black Pink/Gray/Black Blue/Gray/Black REACTION Dynamic Seating A. Sitting Depth B. Trunk Depth C. Trunk Width D. Hip Width E. Top of Shoulder to Seat F. Lower Leg Length Figure 1 - Client Measurements FAST Height Adjustable Activity Base Height Adjustable Activity Base, Seat to floor heaight 13"-21", 40 degree tilt, Available dynamic function,4 locking casters. Height Adj. Base - Dynamic $1, E2295 REACTION Active Component Upper Body Spring Options Soft - Pair Medium - Pair Hard - Pair No Springs Front Rigging must be selected when ordering Reaction TM Active Component. Knee angle adjustment in 15 increments with press of button. E0990 Requires Angle Adjustable Leg Rests 90 Fixed Front Rigging Angle Adj. Elevating Leg Rest Lower Body Spring Options Soft - Pair Medium - Pair Hard - Pair No Springs $ STD $ Page 1 of 5
2 K Fixed Foot Plate Std Inverted Angle Adjustable Foot Plate Std Inverted 35 Dorsal/Plantar Flexion; 10 Positions; 7 increments up /down. Foot Plate Options STD K0040 Angle Adjust Flip-Up Foot Plate Std Inverted Std = " Leg Drop Inverted = " Leg Drop Riser may be substitued in place of inverted foot plate depending upon configuration. Kids UP LifeForm Seat Cushion Options (Choose from A, or B) A. Planar Seat Cushion - Black Mesh Upholstery B. Contoured Seat Cushion - Black Mesh Upholstery E2292 6"-9" Depth $ Includes: 2 Positioning Wedges, Abductor Wedge E2292 8"-11" Depth $ E2294 6"-9" Depth E "-14" Depth $ E2294 8"-11" Depth E "-14" Depth Seat Cushion Pressure Relief and Wedges (for A, or B) Pressure Relief Layer: Memory Foam (1/2" thick) $60.00 Anti-Thrust Wedge for Seat Cushion (12" x 6" x 1") $40.00 Contoured Seat Cushion Ischial Inserts (Contoured Only) Open Cell Foam Soft Memory Foam Medium Memory Foam STD $50.00 $50.00 Contoured Seat Cushion Options (Contoured Only) Extra Positioning Wedges (4) $35.00 Synergy Seat Cushion Options E2607 Synergy Solution Cushion 10"x10" E2607 Synergy Solution Cushion 10"x12" E2607 Synergy Solution Cushion 12"x10" E2607 Synergy Solution Cushion 12"x12" E2607 Synergy Solution Cushion 12"x14" Kids UP Lifeform Back Cushion Options (Choose A or B) E2291 A. Planar Back Options B. Contoured I-Back Options Not available with Lateral Thoracic Supports Adjustable Height Back System with Planar Back Cushion $ I-Back Required for Secondary Positioning Accessories; Contoured Back Cushion includes: 4 Contouring Wedges; Lumbar Support E2293 Configurable, Adj. Height I-Back Sys. w/contour Cushion $ Select a Planar Back Cushion 12" - 15" Planar Back Cushion 14" - 19" Planar Back Cushion Omit Planar Back Cushion Less $68 Select a Contoured Back Cushion 11-15" Contour Back Cushion 14-20" Contour Back Cushion Omit Contoured Back Cushion Less $135 Block Letters Back Cushion Embroidery (Emboridery is applied to colored panel) Script Letters Inscription, Please place one letter per box Blue Thread Red Thread Black Thread Green Thread Purple Thread White Thread Page 2 of 5
3 E0973 Adjustable Height Armrest Thin Profile - Pair Not Available with Integrated Pelvic Thigh Supports Armrest Type (Armrest Pad Length = 6") $ E0973 Adjustable Height Armrest for $ Integrated Pelvic/Thigh Supp. Not Available with Lateral Pelvic/Thigh Supports Tray Options E0950 Upper Extremity Positioning Platform Color - Clear $ E0950 Upper Extremity Positioning Platform Color - Gray $ Support Hardware - Angle/ Depth Adj. Req. for all trays $ Rear Wheel Selections D12C 12" Composite Wheels Full Poly STD Caster Selections 8" x 2" Polyurethane Casters STD Lateral Pelvic/Thigh Supports Left Pelvic/Thigh Support Pkg. $ Left Integrated Pelvic/Thigh Supp.* Right Pelvic/Thigh Support Pkg. $ Right Integrated Pelvic/Thigh Supp.* *Integrated Pelvic/Thigh Supports require Armrest Type $45.00 $45.00 Lifeform Anterior Pelvic Positioning Belts Medial 4-point belt recommended with REACTION seating. Positioning belts not for use as an occupant restraint during transit in a motor vehicle. E0978 LifeForm 2-point 1" Metal PB Buckle, $88.00 E0978 LifeForm Medial 4-point 1" Metal PB 3.5" pads Buckle, 4.5" pads E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 3.5" pads Lifeform Anterior Trunk Supports Anterior Trunk Supports NOT for use as a occupant restraint during transit in a motor vehicle. LifeForm Contoured Dynamic LifeForm Zipper Opening Dynamic Contoured - Early Intervention Zipper Opening - S Contoured - XS Contoured - S LifeForm Zipper Opening Structured LifeForm Contoured Structured Structured Zipper Opening - S Contoured Structured - S Lifeform Swing-Away Abductor Hardware and Pads 4-way stretch cover included with Lifeform Abductor pads. FAST S/A Abductor Hardware $ Small Wedge(2"-3"W x 4"L x 3"D) Med. Wedge (2"-4.5" x 5"L x 3"D) Lg. Wedge (3"-5" x 5"L x 4"D) E0955 E0955 Lifeform Headrest and Support Hardware 4-way stretch headrest cover is included with headrest pads. 8" Curved Oval Pad $ LifeForm Removable Headrest Mounting Hardware 10" Curved Oval Pad $ (Required for LF Headrest Options) E " Curved Oval Pad $ Universal Head Rest Mount Plate Only* $50.00 E0955 Narrow Adjustable Arc Pad $ *Accomodates several other manufacturers headrests. Call for details. $ Page 3 of 5
4 Lifeform Ankle and Foot Positioning Stealth Hard Side Foot Stabilizers Small, Pair, Left and Right $ Medium, Pair, Left and Right $ LifeForm Ankle Hugger Foot Stabilizers Left - Small Right - Small Left - Medium Right - Medium Lifeform Swing Away Lateral Support Hardware Choose your bracket and CURVED pad size Left 1.5" pediatric bracket lateral thoracic support package, Curved Pad Choose your bracket and PLANAR pad size Left 1.5" pediatric bracket lateral thoracic support package, Planar Pad Right 1.5" pediatric bracket lateral thoracic support package, Curved Pad Right 1.5" pediatric 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) Requires or Not Available with teardrop laterals. Left 1.5" DoubleSwing pediatric swingaway Right 1.5" DoubleSwing pediatric swingaway Choose Swing-Away Hardware (required) Requires or Not Available with teardrop laterals. Left 1.5" DoubleSwing pediatric swingaway Right 1.5" DoubleSwing pediatric swingaway LifeForm Swing-Away Width and Depth Extensions (Optional) Options Available only with Swing-Away Hardware. Depth Ext. + 1", pediatric, Left Depth Ext. + 1", pediatric, Right Width Ext. + 1", pediatric, Left Width Ext. + 1", pediatric, Right Choose your bracket and CURVED pad size Left 1.5" fixed pediatric bracket lateral thoracic support package, Curved Pad Lifeform Fixed Lateral Support Hardware Choose your bracket and PLANAR pad size Left 1.5" fixed pediatric bracket lateral thoracic support package, Planar Pad Right 1.5" fixed pediatric bracket lateral thoracic support package, Curved Pad Right 1.5" fixed pediatric 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" Page 4 of 5
5 Additional Support Accessories E1029 O2 holders and tanks are NOT tested with Transit and must be removed prior to tie down. Battery/Accessory Tray* Ventilator Holder/Battery Tray* for LTV Ventilator Series Only. $ $ E2208 Oxygen Tank Holder K0105 IV Support Pole * Battery/Accessory Tray and Ventilator Holder/Battery Tray require special frame configuration and are not retrofitable Accessories Misc. Accessories Replacement Springs Bottom Storage Carrier (not available with Vent or Accessory Tray) $ Upper Body - Soft - Pair Upper Body - Med - Pair Contoured Seat Cushion Covers Upper Body - Hard - Pair Cover Only - 6" - 9" Lower Body - Soft - Pair Cover Only - 8" - 11" Lower Body - Med - Pair Cover Only - 10" - 14" Lower Body - Hard - Pair Planar Seat Cushion Covers Cover Only - 6" - 9" Cover Only - 8" - 11" Cover Only - 10" - 14" Custom Notes: Page 5 of 5
SHIPPING INFORMATION Provider Acct #:
May 2014 Kids ROCK TM Size 2 Order Form Maximum Weight Capacity 115 lbs. 14"Wx16"Dx22"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
SHIPPING INFORMATION Provider Acct #:
May 2014 Kid's ROCK TM Size 3 Order Form Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
SHIPPING INFORMATION. Order
Size 3 Order Form MASS 2014 Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Pride Mobility Products Aust Pty Ltd 20-24 Apollo Drive Hallam VIC 3803 Ph: 03 8770 9600 Fax: 03 9703 2960 Date:
Convaid Trekker 2 - HCPCS E1234 Retail Price List / Order Form
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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
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
JAY Fit. Backrest and Seat Assembly. July 2017
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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
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
Positioning Components Order Form - ODJFS Only
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Positioning Components Order Form - ODJFS Only Account Number: Date: Provider
[ ] Quote [ ] Order. Junior US Retail Price List. Account Information. Ship To Information. Standard Features.
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Account Information Date Account Number Branch Dealer Contact Phone Fax Email Address PO Number Mark For Ship To Information [ ] Quote [ ] Order Shown with Optional Equipment Standard Features Name Address
FUSION Seating Prescription Form Custom Built Seating System
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R82 Kudu - E1233. Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features: Recline No HCPCS Code Assigned to Kudu sz 4
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R82 Kudu - E1233. Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features: Recline No HCPCS Code Assigned to Kudu sz 4
Account #: Purchase Order No.: Contact: R82 Kudu - E1233 Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Kudu Standard
R82 Stingray. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: City/State/Zip: Effective: 2/01/ Rev 7.
R82 Stingray CAD Retail Price List/ Order Form Account #: Purchase Order No.: Date: Contact: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US Configuration
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
Chair Back Solid. Chair Back. Chair Back. Chair Back
Seats and Backs Seats and Backs Solid Up to 14 x 14... 0625 Up to 18 x 18... 062501 Up to 22 x 22... 062502 I-Modification Up to 14 x 14... 06258 Up to 18 x 18... 062510 Up to 22 x 22... 062511 T-Modification
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)
R82 Stingray - E1233
Account #: Purchase Order No.: Contact: R82 Stingray - E1233 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
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:
R82 Kudu - E1233. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features:
Account #: Purchase Order No.: Contact: R82 Kudu - E1233 CAD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Kudu Standard
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
Quantum 6400Z Series Group 4 Single Power & Multiple Power Order Form 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone:
FUZE T50. Order Form USA. Please send your completed order form by to or by fax to
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FUZE T50. 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.
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Quickie IRIS January 2014
Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: ST: ZIP: Address: Dealer Phone: ( ) Fax: ( )
C300 Corpus Tilt. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
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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
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
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 Great for Kids Easy for Moms, Dads and Caregivers! Finally, a tilt-in-space mobility system that brings it all together.
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
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:
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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By Ormesa New 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List in USD Phone: 800-327-0681 Nov-17 Fax: 260-665-3047 Email: iim@mobility-usa.com Quote: P.O. www.mobility-usa.com Bill To
FUZE T20. 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 * Tag v.070118 Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a
FUZE T20. Order Form - Canada Prices in Canadian 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.070118 Shipping Address * * required F r a
Quickie IRIS FSS Net Order Form/Price List (SIN F-1)
Mark For: Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: Dealer Phone: ( ) Fax: ( ) Confirmation Email: Confirm Via: ZIP: Quickie IRIS FSS Net Order Form/Price List (SIN
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
KID-KART TLC... 3 BASE... 3 BASE - Discontinued... 3 SILVER BASE... 4 CASTER FORK ASSEMBLIES... 5 WHEEL LOCKS... 6 ANTI-TIPS... 7 REAR WHEELS...
KID KART TLC PAGE 1 KID-KART TLC... 3 BASE... 3 BASE - Discontinued... 3 SILVER BASE... 4 CASTER FORK ASSEMBLIES... 5 WHEEL LOCKS... 6 ANTI-TIPS... 7 REAR WHEELS... 8 STROLLER HANDLE... 9 KID KART PNEUMATIC
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) Freedom 2 Kids
Freedom 2Kids Manual Wheelchair Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Frame Options FD2K Folding Transport Optional (E1236) or (K0005) FD2K-30270 $2085 Note: Transportation
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:
Convaid, the company that invented the adaptive assisted wheelchair, has helped special
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JAY AES - PACKAGE ORDER FORM November 2012
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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
Vision Ultra-single power
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Phone: Jan 17. Fax: usa.com Quote: P.O. usa.com Bill To
By Ormesa New 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 800 327 0681 Jan 17 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility usa.com Bill To Dealer:
USA Parts List FUZE T50
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2016 EZ RIDER UPRIGHT PRODUCT PPT
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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
BENTLEY. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.
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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)
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 GL. 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.070118 Shipping Address * * required F r a
Convaid, the company that invented the adaptive assisted wheelchair, has helped special
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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
Quantum 600 Series Group 3 Single Power & Multiple Power Order Form/ODJFS Only 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA
INDUSTRIES, INC. PRODUCT CATALOG C121
METALCRAFT INDUSTRIES, INC. Note About Digital Catalog Note About Digital Catalog Text In This Digital Catalog That Are Highlighted Are Linked To Other Parts Of The Highlighted Text In This Digital Catalog
Traxx 3 & Atigra 2 Script Form
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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:
R82 Wombat Living. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: Date: Wombat Living Standard Features:
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Bio-ST ST & ST-HD. Modifications Removable and/or Additional Foam Shape Contour Covers A A A A & A
Information is provided to: Quote Up-Date a Quote Q Order Quote # Q Purchase Order # Ordered By: Client s Name (Last, First):, Sales Person (RTS): Phone: Fax: E-Mail: Inside Contact: Phone: Fax: E-Mail:
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) PRO-CG. Adult Manual Wheelchair
PRO-CG Adult Manual Wheelchair email: customerservice@freedomdesigns.com TM SE Clear Form Email Form to Customer Service Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Notice: A seating
Customer code C- Invoice address. Max. 90 kg See page 5 Side upholstery (reduces SW with 2 x 2 cm) = Standard equipment
Date Customer code C- Invoice address Contact person Reference Other delivery address Quote Invoice address = delivery address Basic price: 3.495,- excl. VAT Seat width D2025 D2030 D2035 25 cm 30 cm 35
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
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
BENTLEY. Order Form - AADL - W322 Prices in Canadian Dollars. October 1, W h e e l L o c k s. A n t i - T i p p e r s. B a c k P o s t S t y l e
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 Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a m e T y
Canadian Suggested Retail Price List April 2015
Size 5 Canadian Suggested Retail Price List April 2015 Account No. Drop Ship: Date: Name P.O. Number: Address Buyer: City Marked For: State Zip E Mail: Tel. Fax A ( Back height) B (Arm height) C (Lower
Table of Contents. Order By: Trays. Positioning Straps. Seats and Backs. Bracket Hardware. Electronics. Seating Accessories. Order Forms.
Products Catalog 2012 Table of Contents Richardson Products manufactures and distributes a broad spectrum of rehab and home medical equipment. Our products are manufactured using the highest quality materials
Tilt in space up to 60 degrees Comfort seating Max. user weight: 113kg. Height adjustable folding back Heavy Duty version 158kg
QUICKIE IRIS Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: E-Mail: E-Mail: Tel: Fax: Tel: Order date: Marked for: Purchase order: Number required: Sunrise order no: Base
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.
NXT Pediatric. Manual Wheelchair. Transport Optional Base
Pediatric Manual Wheelchair Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Transport Optional Base Folding (E1234) NXT-30300 $2800 Transport Optional Note: Transportation Option selected
USA Parts List FUZE T20
USA Parts List FUZE T20 Effective January 1, 2018. Prices in U.S. Dollars. Prices and descriptions contained in this manual are subject to change without prior notice. Fuze T20 Frame-Seat Pan Cross Bar
Frame. Pos Item number Description Comment
Titel - 1 - Titel - 2 - Table of Content Zippie Voyage... 4 Basic Equipment... 4 Frame... 4 Slide-N-Lock Interface... 5 Transit Kit... 6 Canopy... 7 Seat, Back... 8 Seat Base... 8 Seatback... 10 Seat Cushion...
q Little Wave Flip XP - Rigid Base KF-XPRIGID $
Phone 0800 5 222 Fax 0800 275 65 Effective /06/207 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Little Wave Flip XP - Rigid Base KF-XPRIGID $ 9.8kg weight capacity. One time free
Manufacturer: Model: Seat width: cm Seat depth: cm
Thompson House Unit 10, Styles Close, Sittingbourne, Kent ME10 3BF Tel: 01795 477280 Fax: 01795 229692 Email: sales@rms-kent.co.uk web: www.ineedawheelchair.co.uk Caddy modular seating system order form
REVERSIBLE OUTER COVER: >PELVIC OBLIQUITY KIT
POSTURE SEAT MaTRx PS cushion is designed to provide superior positioning, stability and comfort. The design features an anatomically contoured shape with a unique waffled ischial relief recess, and an
USA Parts List BENTLEY
USA Parts List BENTLEY Effective January 1, 2018. Prices in U.S. Dollars. Prices and descriptions contained in this manual are subject to change without prior notice. Bentley Frame-Seat Pan Floor Jack
cp tech customised product technology Product Catalogue
cp tech customised product technology Product Catalogue CONTENTS 1. How to Measure a Postural Insert 2. Insert Components - Back and Base - Cushions - Lateral Supports - Head Supports - Pommels - Foot
Invacare Series ContourU Model #'s CM01S, CM01B, CM02S, CM02B
Invacare Series ContourU Model #'s CM01S, CM01B, CM02S, CM02B For 3D Image Systems: E-mail Order Form and Digitized File to: ElyriaCustomSeating@invacare.com Company Name: Date: Account #: Contact Name:
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....
Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018
TRACER EX2 FOLDING WHEELCHAIRS Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018 PROVIDER NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS Invacare Canada
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
Product List V Adaptive Engineering Lab 102 E Keefe Ave Milwaukee, WI 53212
Product List V2016.1 Adaptive Engineering Lab 102 E Keefe Ave Milwaukee, WI 53212 P: 866.656.1486 F: 866.656.1487 E: sales@aelseating.com W: AELseating.com Published August 1, 2016 TABLE OF CONTENTS >Positioning
Adjustable Height Raised Toilet Seat Model 101 RTS Pricelist/Order Form December 2014
Adjustable Height Raised Toilet Seat Model 101 RTS Date: Name: P.O.#: Address: Name: City/State/Zip: Mark For: Phone: Account #: Fax: This Activeaid raised toilet seat is unique in its design to accommodate
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
Quickie QX July 2017
Quickie QX July 2017 EIF6 Mark For: Submitting for: Date: PO#: Quote Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: Dealer
PRESCRIPTION FORM. Delivery address. Purchase order. Shipment date Delivery Date. Type
PRESCRIPTION FORM Distributor Branch Client Phone Delivery address (Use 'Shift'+'Enter' for new line) Salesperson E-mail Purchase order Type Date Shipment date Delivery Date Important Demo Request Order
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:
q Little Wave Flip XP-Rigid Base E1233, E1161 $
Funder: Therapist: Date: q MOH q ACC Marked For: Details: Ship To: Address: City: Postcode: Phone: Email: Notes: q Little Wave Flip XP-Rigid Base E1233, E1161 $ 74 kg weight capacity. Price includes one
Quickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,
Quickie QXi AADL EIF6, October 2018 Mark For: Submitting for: Date: PO#: Quote Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City:
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG. Adult Manual Wheelchair
P.R.O. CG Adult Manual Wheelchair TM SE 2241 N Madera Rd Simi Valley, CA 93065 Phone: (800) 331-8551 Fax: (888) 582-1509 www.freedomdesigns.com email: customerservice@freedomdesigns.com Date: Buyer: Company:
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
Complement your Zippie with the JAY Zip Cushion and Back designed just for kids! Pediatric Wheelchair Portfolio
4 Complement your Zippie with the JAY Zip Cushion and Back designed just for kids! Pediatric Wheelchair Portfolio JAY Zip Back Versatile One Step Release Hardware Easy one step release Fits on wide range
Invacare Kite (Modulite Flex3 Seating System) Dealer Max User Weight 160Kg (25 stone)
Invacare Ltd Power Prescription Form Pencoed Technology Park Dealer Prescription Form Pencoed CF35 5AQ LPF1U2KITEFLEX011015Dealer Tel: +44 (0) 1656 776222 Fax: +44 (0) 1656 776220 July 2015 email: ordersuk@invacare.com
CUSTOM INCEPTION CUSHION ORDER FORM HCPC CODE: E2609
CUSTOM INCEPTION CUSHION ORDER FORM HCPC CODE: E2609 CUSTOMER/PATIENT INFORMATION Date: Company Name/ACCT #: Patient Name: Patient Weight: Patient Height: P.O. Number: Requested By: Phone: Email: Ship
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
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
Quickie QX December 2018
Quickie QX December 2018 EIF6 Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: PV:
JIVE F/R: 5,650 9,193 JIVE M: 5,895 9,591
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: Standard Features Angle adj. footplate
Tailored seating solutions for the user requiring a custom CONFIGURED product with the ultimate personal FIT.
C ONFIGUREF IT Tailored seating solutions for the user requiring a custom CONFIGURED product with the ultimate personal FIT. Alignment to Reimbursement: Ease of Ordering: Improved and Expanded Product
Synthesis Tilt Recliner Model: V4
PO: Date: Customer #: Customer Name: Address: Phone: Contact: Email: Ship To Name: Address: Phone: Contact: Tag: Standard Features Comfort Tension Seating 350lb Weight Capacity Up to 40 Infinitely Adjustable