Invacare Series ContourU Model #'s CM01S, CM01B, CM02S, CM02B

Transcription

1 Invacare Series ContourU Model #'s CM01S, CM01B, CM02S, CM02B For 3D Image Systems: Order Form and Digitized File to: Company Name: Date: Account #: Contact Name: Ship To Address: Address: City/State/Zip: Phone Number: Client Reference: Purchase Order #: Custom Molded CLIP file name: *Note: CLIP file name= 1st Initial, 1st 3 of last name & Account # Brand: Frame Width: Length inches: Seat to Back Angle: Mobility Base Information Model: Frame Depth: Cushion Information LEFT: RIGHT: LEFT: RIGHT: Adductor Height inches: Abductor Height inches: On Chair Information Invacare to mount cushions to NEW Invacare Chair When ordering this order form and Invacare Chair order form to: elyriacustomseating@invacare.com or provide quote # below: Invacare quote # : Freedom Designs to mount cushions to NEW Freedom Designs Chair If a Freedom Designs chair quote is to be converted please call Cushions will be drop shipped to Freedom Designs. Freedom Designs quote / PO # : Motion Concepts to mount cushions to NEW Motion Concepts Chair If a Motion Concepts chair quote is to be converted please call Cushions will be drop shipped to Motion Concepts. Motion Concepts quote / PO # : Universal Hip Control Seat to Back Junctions Junction Growth in Inches Open to Rear Fixed Recline (>105) * N/A Yes No Pelvic Control N/A N/A Fixed Angle ** N/A N/A * Default junction if nothing is selected is Fixed Recline, open to the rear, no gap ** Required if using FDI-538 hardware Inches of Gap Style of Gap Full Only Universal: (Most Common <105⁰) Pelvic Control: Fixed Angle: Posterior pelvic wall built into the back cushion Posterior pelvic wall Posterior pelvic wall in seat & back 3" rear Hip Guides built into seat cushion 45⁰ Angle Cut Low Pivot Point for seat to back angle adjustment 3+" rear Hip Guides Use with the FDI-538 Hardware Depth Adjustable and Angle adjustable up to 105⁰ No depth / angle adjustment No Depth / Angle Adjustment Growth available No Growth available No Growth available Std. Tongue Std. Tongue Full Tongue Full Only Full Full Hip Control: Posterior pelvic wall built into the back cushion 1" rear Hip Guides Low Pivot Point for seat to back angle adjustment Depth Adjustable and Angle adjustable up to 105⁰ Growth available Fixed Recline: (Most Common >105⁰) Posterior pelvic wall built into the seat or back cushion Best option for >105 degree seat to back angle Seat to back angle built into the cushion Depth Adjustable & Angle adjustable up to 105⁰ No Growth available elyriacustomseating@invacare.com Revised 5/1/18 Page 1 of 5

2 Soft Foam Standard Foam Vinyl Cushion Naked Cushion BKV Black Vinyl Cushion Options Vinyl Cover Selection GMC Gunmetal Grey Vinyl Naked Cover Selection DT-2 Standard Dartex DT-2R Reversed Dartex L-18 Purple Rubber Backed Lycra L-24 Spacer Mesh Foam Options WWV Wedgewood Blue Vinyl SAV Sage Green Vinyl TAV Taupe Vinyl PGV Purple Grey Vinyl CMP Polartek CMS Lycra CMD Darlexx L-05 Black Rubber Backed Lycra L-06 Gray Rubber Backed Lycra L-13 Light Blue Rubber Backed Lycra L-14 Red Rubber Backed Lycra L-15 Teal Rubber Backed Lycra L-19 Burgundy Rubber Backed Lycra L-20 Blue Rubber Backed Lycra L-23 Green Rubber Backed Lycra Cover Style Selection Drawstring Standard 2 Piece Velcro $65.00 Zipper with Velcro Bottom..... $65.00 Additonal Cover Selection Seat Specifications (Non-removable) (Fabric Drawstring Cover Included) CM78S Cover for Vinyl Cushion. $ CM76S Cover for Naked Cushion $ Qty: Fabric: S040 Inner Water Resistant Cover (Zipper)... $ HCPCS E2609 $1, When opting for a 2- tone fabric selection indicate "A" for contact surface, "B" for noncontact surfaces CM31 Upholstered Bottom without Velcro... $75.00 CM31V Upholstered Bottom with Velcro... $ CM06T Wood Mount with t-nuts.... $ Specify Non-std t-nut pattern: _ CM06 Wood Mount with out t-nuts..... $ TFNP New PinDot Pan..... CTNP PinDot to cut pan to fit long leg.. TFEP Fit Existing Pindot Pan W: x L: CM03 Untrimmed (vinyl only) FDI-538 Econo-Eze (includes Seat & Back) HWPMK01 Pan Mounting Kit - 1"... HWPMK78 Pan Mounting Kit - 7/8".... HWWMK01 Wood Mounting Kit - 1"..... HWWMK78 Wood Mounting Kit - 7/8"..... OCMK01 J & L Brackets - 1"... OCMK01 J & L Brackets - 7/8".. OMIT Omit Hardware Lateral Thigh Support Options Right Side CM46 As Molded.... CM47 Raised ".... CM36 Extended " Left Side.... CM46 As Molded.... CM47 Raised " CM36 Extended " Mounting Mounting Hardware... Medial Thigh Support Options CM48 Standard L- Shaped Reinforcement. CM50 Laminated Reinforcement CM80 Aluminum Reinforcement... $ $85.00 $ $ $ CM54 As molded.... CM37 Raised " CM34 Extended "..... Reinforcements $ elyriacustomseating@invacare.com Revised 5/1/18 Page 2 of 5

3 Seat Modifications Seat Specifications Soft Spot / Overlay / Recess Option CM38 Loose Fit 1/4" increments " CM09 Softspot - Standard Foam. $ CM22 Rail Cut - Railcut width " CM13 Undercut " CM09V Softspot - Visco Foam.... $ CM40 Diagonal Cut (provide dimensions)... CM12 Pelvic Strap Notches 2" Standard... VF05 Visco Foam Overlay 1/2".. $ CM17 Notched Rear Corners 1 1/2" x 2"... VF01 Visco Foam Overlay 1". $ CM33 Cross-brace Notch (provide dimensions) $ SF05 Standard Softspot Foam Overlay 1/2"... $ CM20 Strap Slots (1/2" x 1 1/2" std, naked only) - Qty: $ SF01 Standard Softspot Foam Overlay 1".. $ VH02 Vent Holes (naked only) - Qty: $ CM30 Recess only- Depth: " CM23 Front Rigging Notches (standard 2 x 2 x 2) $ CM30G Recess with Silicone Pad.... $ Right: Width Length Depth STAR Recess with Star Airflow Insert Left: Width Length Depth 14" Wide..... $ " Wide.. $ " Wide.... $ Recess with Action Gel Insert..available after 6/15/18 ACTF Action Free Float * $ / $ ACTW Action Waffle * $ / $ ACTP Action Pebble * $ / $ *Size determines price >17" higher price applies Special Requests not on the Seat Order Form elyriacustomseating@invacare.com Revised 5/1/18 Page 3 of 5

4 Soft Foam Standard Foam Cushion Options Vinyl Cushion Naked Cushion BKV Black Vinyl CMS Lycra CMD Darlexx Foam Options WWV Wedgewood Blue Vinyl SAV Sage Green Vinyl TAV Taupe Vinyl CMP Polartek Back Specifications HCPCS E2617 $1, TFNP New PinDot Pan $ TFEP Fit Existing Pindot Pan W: x L: CM03 Untrimmed (vinyl only)... CM31V Upholstered Bottom with Velcro $ CM31 Upholstered Bottom without Velcro..... $75.00 CM06T Wood Mount with t-nuts $ Specify Non-std t-nut pattern: _ Specify HeadRest t-nut pattern: CM06 Wood Mount without t-nuts $ TFCS To Fit Custom Shell $ Exisiting Shell Type: HWABK Adjustable Back Hardware $ HWPMK01 Pan Mounting Kit - 1". HWPMK78 Pan Mounting Kit - 7/8".... HWWMK01 Wood Mounting Kit - 1" HWWMK78 Wood Mounting Kit - 7/8" OCMK01 J & L Brackets - 1".. $ OCMK01 J & L Brackets - 7/8" $ FDI-538 Econo-Eze (includes Seat & Back).. $ FDI-596 Econo-Eze (Back only) $ OMIT Omit Hardware DT-2 Standard Dartex When DT-2R Reversed Dartex opting for a Lateral Trunk Support Options 2- tone L-05 Black Rubber Backed Lycra fabric Right Side L-06 Gray Rubber Backed Lycra selection CM49 As Molded.... indicate L-13 Light Blue Rubber Backed Lycra "A" for CM51 Square Pull ". L-14 Red Rubber Backed Lycra contact CM36 Extended Existing Shape " surface, L-15 Teal Rubber Backed Lycra "B" for Left Side noncontact CM49 As Molded.... L-18 Purple Rubber Backed Lycra L-19 Burgundy Rubber Backed Lycra surfaces CM51 Square Pull ".... L-20 Blue Rubber Backed Lycra CM36 Extended Existing Shape "... L-23 Green Rubber Backed Lycra L-24 Spacer Mesh Cover Style Selection (Non-removable) (Fabric Drawstring Cover Included) Vinyl Cover Selection PGV Purple Grey Vinyl GMC Gunmetal Grey Vinyl Naked Cover Selection Drawstring... Standard 2 Piece Velcro... $65.00 Zipper with Velcro Bottom..... $65.00 Mounting Mounting Hardware Reinforcements CM16 Standard L- Shaped Reinforcement... Standard CM39 Laminated Reinforcement..... CM21 Aluminum Reinforcement.... $ Swing Away Laterals CM53R Swing away Lateral Right (Naked only) $ Additonal Cover Selection CM53R Swing away Lateral Left (Naked only). $ CM78S Cover for Vinyl Cushion.. $ Swing away laterals must include: CM76S Cover for Naked Cushion $ Aluminum Reinforcements CM06T Wood mount w/ t-nuts Quantity Fabric Cannot be made with a rail cut Cushion must be 7" or deeper S040 Inner Water Resistant Cover (Zipper)... $ Recommended for one side only Zipper Cover elyriacustomseating@invacare.com Revised 5/1/18 Page 4 of 5

5 Back Specifications Back Modifications CM38 Loose Fit 1/4" increments " CM09 Softspot - Standard Foam. $ CM22 Rail Cut - Railcut width " CM13 Undercut " CM09V Softspot - Visco Foam.... $ CM40 Diagonal Cut (provide dimensions)... Q CM20 Strap Slots (1/2" x 1 1/2" std, naked only) - Qty: $ VF05 Visco Foam Overlay 1/2".. $ VH02 Vent Holes (naked only) - Qty: $ VF01 Visco Foam Overlay 1". $ SF05 Standard Softspot Foam Overlay 1/2"... $ SF01 Standard Softspot Foam Overlay 1".. $ CM30 Recess only- Depth: " CM30G Recess with Silicone Pad.... $ Recess with Action Gel Insert..available after 6/15/18 Monogram... $65.00 ACTF Action Free Float * $ / $ Style Block Cursive ACTW Action Waffle * $ / $ Thread Color: White Blue ACTP Action Pebble * $ / $ Pink Yellow *Size determines price >17" higher price applies Teal Red Name: (Name will be centered top 3/4" front of back cushion) Soft Spot / Overlay / Recess Option Accessories AR20 Desk Length Armrest (Pair)... $ TR40L Tray Receptacle - Left $ AR24 Full Length Armrest (Pair)... $ TR40R Tray Receptacle - Right.... $ LB07 Small Footrest (Pair).. $ GL01 Regular Links... $ LB08 Large Footrest (Pair).. $ GL03 Extra Strong Links..... $ LT06 Legrest Tops (Pair). $ GL10 Dial Links ( seat angle must be > 105 )... $ SB05 ContourU Pelvic Strap $45.00 Headrest Adapter Plate* $45.00 * will not work with Freedom t-nut pattern Special Requests not on the Back Order Form elyriacustomseating@invacare.com Revised 5/1/18 Page 5 of 5