Quickie 7 R. January 2019 EIR11. ADDITIONAL SHIPPING INFORMATION Dealer Contact:
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- Milo Matthews
- 5 years ago
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1 Quickie 7 R January 2019 EIR11 Mark Fr: Submitting fr: Qute Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: ST: ZIP: Address: Dealer Phne: ( ) Fax: ( ) Address: Cnfirmatin Ship T City: ST: ZIP: Cnfirm Via: Fax Ship T Phne: ( ) Fax: ( ) a Optin # The HCPCS CODES prvided are based n cde verificatin thrugh PDAC r ur interpretatin f the cde definitins. The use f HCPCS CODES des nt ensure cverage r payment. Fr cverage infrmatin, verify the apprpriate payer's cverage plicy. HCPCS Definitin Price a 1. FRAME Optin # HCPCS Definitin Price Weight capacity 265 lbs 132WM88 Base Mdel Quickie 7 K0005 R - Adjustable $2, Use E1235 fr sizes 14" r less Perfrmance Package (N substitutins, discunt given n separate line) 132QD01 Single Sided Frk $ Ultra Lightweight Wheel $ Schwalbe Marathn Plus Evlutin $ Cmpact Wheel Lck Retail Value $ Package Price $ Ultra Lite Package (N substitutins, discunt given n separate line) 132QD02 Ultra Lite Seat Sling Ultra Lightweight Wheel $ Schwalbe Speed Run Tire $ Cmpact Wheel Lck Retail Value $ Package Price $ Frame Angle See FIGURE 1 Measure frm frnt frame t flr. 132FA1 132FA FA2 85 See FIGURE 2 Frame Inset is the distance frm the utside f the seat tube t the utside f the ftrest. 132FF1 132FF2 132FF3 0" 1" ( w/ 12" wide) 2" ( with 12" & 13" wide) Frame Style See FIGURE 3 Measurement fr set up. 132FS9 Standard 132FS34 Classic * Standard Frame - Seat Sling t frnt frame bend angle is 1.5" shrter than the classic psitin. Classic Frame - Traditinal seat sling t frnt frame bend angle dimensins. Frnt f back cane pst t frnt edge f seat sling will remain the same fr bth Standard and Classic. Frame - Direct Munt Wheel Lck (Optinal) Only available with Cmpact Wheel Lck, 0 & 3 Camber and rear wheels. N munting clamp hardware, with Aluminum r carbn fiber sideguards. with muntain tires r rear suspensin. in 12"-15" seat depths. with height adjustable armrests. 132WH13 132TO45 132IN04 Direct Munt Wheel Lck Transit Transit System Attitude Bike (Optinal) Attitude Bike bundle Frame Inset Per Side $ See Order Frm Figure 1 Figure 2 Figure 3 Custmer Service: Fax: rders@sunmed.cm Page 1
2 2. SIZE / SEATING Depth Adjustable Backrest (Optinal) See Figure 4 Depth Adjust Backrest extends the frame rear f the seat sling, select a factry setting. 132DP02 132DP03 132DP04 0 Backrest at standard psitin, field adjustable t -1" r -2" Figure 5 Figure 6 $ Backrest -1" ffset, field adjustable t flush r -2" $ Backrest -2" ffset, field adjustable t flush r -1" $ Figure 4 Seating Systems Standard Seat Sling 132OP01 132OP02 Available 14" t 18" Widths and Depths. Ultra Seat Sling will be ~1/4" less than requested seat height value. 132OP04 Omit Seat Sling 132CU1 Ultra Seat Sling Seat Width See FIGURE 5 Measure frm utside f seat tube t the utside f ppsite seat tube. 132S3 132S4 132S5 132S6 132S7 12" 13" 14" 15" 16" 132S8 132S9 132S10 132S48 17" 18" 19" 20" (E2201) $ Seat Depth See FIGURE 6 Measure frm frnt f back pst t frnt edge f seat sling. Seat sling is 1" shrter than depth rdered, but actual seat depth will remain the same as rdered. 132SD5 132SD6 132SD7 132SD8 132SD9 12" 13" 14" 15" 16" 132SD10 132SD11 132SD12 132SD13 17" 18" 19" Cushin E0669 2" Cushin $ JAY Cushins (Optinal) T rder any JAY cushins n-chair, please see the JAY price list. Cushin name r part number must be filled ut with desired width and depth JAY Bundled Cushin 132JC20 Cushin Name r Part # Price List Width: Depth: 20" (E2203) $ CASTERS / SEAT HEIGHT Frnt Seat Height See FIGURE 7 Measure frm the frnt f the seat rail t the flr. 132SH " 132SH20 132SH " 132SH21 132SH " 132SH23 132SH " 132SH24 132SH " 132SH26 132SH " 19.0" 19.5" 20.0" 20.5" 21.0" Figure 7 132CF65 132CF69 132CF53 132CF54 132CF55 Caster Frk and Suspensin Multiple Psitin Multiple Psitin Single Sided Frk E1015 Frg Legs 0 weight t 100 lbs. E1015 Frg Legs 101 lbs. weight t 190 lbs. E1015 Frg Legs 191 lbs. weight t 265 lbs. 132CW1 132CW3 132CW31 132CW72 132CW44 132CW64 132CW5 132CW51 132CW6 132CW65 132CW7 132CW66 132CW34 132CW33 132CW35 132CW68 Caster Wheels 3" Micr 4" Lw Prfile Plyurethane 4" Micr Lighted 4" x 1" Aluminum Ply E2219 4" x 1.25 Semi Pneumatic 4" x 1.5" Aluminum Sft Rll 5" Lw Prfile Plyurethane 5" Micr Lighted E2219 5" Sft Rll (Grey) - w/frg Legs 5" x 1" Aluminum Ply E2219 5" x 1.5" Semi Pneumatic 5" x 1.5" Aluminum Sft Rll 6" Ply E2214 6" Pneumatic E2215 E2219 6" x 1.5" Semi Pneumatic 6" x 1.5" Aluminum Sft Rll $ Custmer Service: Fax: rders@sunmed.cm Page 2 $70.00 $ $55.00 $ $ $205.00
3 3. CASTERS / SEAT HEIGHT (CONT) Caster Husing Psitin See FIGURE 8. See Appendix fr example. 1 Suggested fr 3" & 4" casters. 132LH01 Fr 2" Inset w/ setting 1 132LH02 132LH03 2 Suggested fr 5" & 6" casters. 3 w/ 6" casters Figure 8 4. REAR WHEELS / SEAT HEIGHT RSH 13"-15.5" nly w/ 20" Rear Wheel. RSH 15"-15.5" Only w/ 20, 22 r 24" w/hp Clincher Rear Wheel. RSH 16"-16.5" w/ 24, 25 & 26" Rear Wheels and Rear Suspensin 132RH " ( w/ Rear Suspensin) 132RH " ( w/ Rear Suspensin) 132RH " 132RH " 132RH " 132RH " 132RH " 132RH " 132RH " Camber 132CI CI CI4 6 ( w/ 5 spk Mag wheel) 132XT6 E " Xtender Pwer Assist JWX-2 NICKEL 132XT7 E " Xtender Pwer Assist JWX-2 LITHIUM 132XT4 E " Xtender Pwer Assist JWX-2 NICKEL 132XT5 E " Xtender Pwer Assist JWX-2 LITHIUM Please select ne f the fllwing handrim ptins 132XH5 132XH6 Plastic Cated Stainless Steel 132RH26 132RH20 132RH27 132RH21 132RH37 132RH22 132XA10 132XA11 132XA8 132XA9 E " 18.0" 18.5" 19.0" 19.5" Rear Seat Height 20.0" ( w/ Rear Suspensin) Xtender Pwer Assist RSH 16.5"-19" with 22" wheels, RSH 17.5"-20" with 24" wheels 0 camber, pneumatic tire. 22" & 24" wheels nly. Anti-Tips n charge. w/ Transit and 4-link Suspensin. Dual Drive mde available with B4ME $8, Xtender - Other Optins Spare NiMH Pwer Pack - NICKEL $1, Spare Li-in Pwer Pack - LITHIUM $1, Xtender Wheel Optins SPARE 22" Lite Spke Pneu Alum SPARE 22" Lite Spke Pneu Plastic $7, $8, $7, Ultra Lightweight nly available w/ Aluminum Handrim. Cntact Built 4 Me fr Spinergy clr ptins 132RW103 20" Mag Wheel 5 Spke 132RW104 22" Mag Wheel 5 Spke 132RW102 24" Mag Wheel 5 Spke 132RW90 20" Lite Spke $ RW91 22" Lite Spke $ RW92 24" Lite Spke 132RW93 25" Lite Spke 132RW94 26" Lite Spke $ RW06 22" Ultra Lightweight Spke Wheel $ RW10 24" Ultra Lightweight Spke Wheel $ RW16 25" Ultra Lightweight Spke Wheel $ RW28 22" Spinergy SPOX Black Spkes $ RW95 24" Spinergy SPOX Black Spkes $ RW96 25" Spinergy SPOX Black Spkes $ RW97 26" Spinergy SPOX Black Spkes $ RW32 22" Spinergy LX Black Spkes 132RW98 24" Spinergy LX Black Spkes 132RW99 25" Spinergy LX Black Spkes 132RW40 26" Spinergy LX Black Spkes 132RW50 24" Muntain $ RT1 132RT2 132RT3 132RT38 132RT39 132RT21 132RT27 132RT12 132RT28 E2213 Rear Wheel Tire Pneumatic Rear Wheel Pneumatic Airless Insert with Xtender Full Ply Tire E2218 SHOX Perfrmance Ply High-Pressure Clincher Black Schwalbe Marathn Plus Evlutin Knbby V-TRAK by Kenda Muntain Only available in 24" Schwalbe Speed Run Tire Frnt t Rear Seat Height Matrix 12" Seat Depth 2.5" Max Frnt t Rear Seat Hgt. 13", 14" Seat Depth 3.0" Max Frnt t Rear Seat Hgt. 15", 16" Seat Depth 3.5" Max Frnt t Rear Seat Hgt. 17", 18" Seat Depth 4.0" Max Frnt t Rear Seat Hgt. 19", 20" Seat Depth 4.5" Max Frnt t Rear Seat Hgt. $ XA2 SPARE 24" Lite Spke Pneu Alum 132XA4 E2213 SPARE 24" Lite Spke Pneu Plastic Custmer Service: Fax: rders@sunmed.cm Page 3
4 4. REAR WHEELS / SEAT HEIGHT (CONT) Tire 5 Spke Mag Lite Spke Wheel Ultra Lightweight Spinergy Pneumatic 20,22,24 20,22,24,26 22,24,26 Pneumatic w/ Airless Insert 20,22,24 20,22,24,26 22,24,26 Full Ply 20,22,24 20,22,24 SHOX Perfrmance Ply 20,22,24 20,22,24,25 24,25 High-Pressure Clinch Blk 22,24,26 22,24 22,24,26 Schwalbe Marathn 24,25,26 22,24,25 24,25,26 Knbby V Trak by Kenda Schwalbe Speed Run 24,25 24,25 24,25 20"= 451 mm 22" = 501 mm 24" = 540 mm 25" = " = AX1 132AX13 Axle Quick Release Steel Quad Quick Release Steel Only available with Muntain Whls Axle Plate Extended COG w/ Xtender Pwer Assist Adjustable COG (1"-4") Adjustable Extended COG (0"-3") $ Handrim Natural Fit Handrims nly available in 22", 24", & 25". Natural Fit w/ 5 spke MAG nly available in 24". See APPENDIX 11 fr matrix 132HR1 Aluminum Andized 132HR4 Plastic Cated w/ 25" & 26" Lite Spke Wheels Rear Suspensin (Optinal) 4-Link Rear Suspensin COG (0"-3") Single Pst nly available up t 2" COG. Plastic Side Guards nly available up t 2.5" COG. w/xtender 132SV08 132SV09 Weight frm 0 lbs t 175 lbs Weight frm 176 lbs. t 265 lbs $ $ HR22 132HR23 Natural Fit - Standard Grip Natural Fit - Super Grip Center f Gravity Preset 132HR25 Natural Fit - N Thumb Grip $ Measure frm frnt f back pst t the center f rear axle. Xtender 1"- 4" 132HR30 Natural Fit LT - Standard Grip $ CC12 0" 132HR31 Natural Fit LT - Super Grip $ CC1.5" 132HR32 Natural Fit LT - N Thumb Grip $ CC2 1.0" 132HR26 The Surge - Oval w/griptin Strip $ CC3 1.5" 132HR27 The Surge LT - Oval w/griptin Strip $ CC4 2.0" 132HR28 Q-Grip Neprene Cated $ CC5 2.5" Spinergy Flex Rim Only available n 132CC6 3.0" 132HR24 $ Spinergy LX wheels 24" & 25" 132CC7 3.5" Omit Handrim 132CC8 4.0" 132HR7 w/ Ultra Lightweight Wheels 5. WHEEL LOCKS Wheel Lck Nt all wheel lcks available in all seat depths, wheel size, r COG 132WL1 High Munt Push 132WL2 High Munt Pull 132WL45 Erg Scissr 132WL30 Cmpact 132WL10 Omit Wheel Lck Wheel Lck Optins 132WL12 D Nt Munt Extensin Handle Ext. handles nly available with high munt push r pull wheel lcks 132EH7 E0961 Extensin Handle (Pair) 6. FOOTREST OPTIONS Ftrest Angle Adjustable Flip Back w/ wide w/ 0 inset. Sme Flip back cnfiguratins wn't allw 2 " grund clearance and will need t raise up. Flip back nt available Caster setting 1" & 2" inset. 132F229 Aluminum Tubular 132F274 Aluminum Tubular w/ Snap On Cver $ F276 K0040 Angle Adjustable Flip Back $ F325 Angle Adjustable FB Carbn Fiber $ F51 K0040 Platfrm Ftrest 132F111 K0040 Ultra Lite Platfrm Ftrest w/ 14" wide and 2" inset, w/ wide w/ 0" inset $ Platfrm Carbn Fiber ftrest 132F323 $ Nt available n 19"-20" W Adaptive Platfrm Spacer with Aluminum Tubular r Ultra Lite Platfrm. 132AD1 Adaptive Platfrm 2" Spacer 132AD2 Adaptive Platfrm 4" Spacer 132AD3 Adaptive Platfrm 6" Spacer 132DI08 132DI03 132DI04 132DI05 132DI07 132DI02 132DI06 K0038 K0038 Ftrest Optins High Munt Ext Tubes ( w/ Tubular ftrest) Leg Strap Extra Leg Strap Gel Hanger Cver Neprene Impact Guards Wear Pads Psitin Plates NA fr Tubular Ftrest $55.00 $40.00 $40.00 $ Custmer Service: Fax: rders@sunmed.cm Page 4
5 7. BACKREST Freestyle Backrest nt available n Active Rigid chairs. See ptin 3 fr details 132BT3 Nn-Flding Angle Adjustable Flding w/ Duble Lck Dwn 132BT96 Angle Adj Back Type 132BT121 Freestyle Backrest Nn- flding 132BT122 Freestyle Backrest Flding 132B B B B137 Chse Optin 1 r 2 1. Aluminum Height Adjustable Backrest 2. Ultra Lightweight Aluminum Fixed Backrest 10 "- 14" Back Height Select back height. 8", 9", r 10" nly available with mit push handles ", 18", r 19" nly available with fld dwn push handles 12 "- 16" Back Height 132BB21 8" 132BB17 14" BB20 9" 132BB18 15" 14 "- 18" Back Height 132BB13 10" 132BB19 16" BB14 11" 132BB10 17" 16 "- 20" Back Height 132BB15 12" 132BB11 18" BB16 13" 132BB12 19" 132QT01 132QT02 132PH6 132PH5 132PH2 Twel Bar Standard Style - 4" Offset Lw Prfile - 2" Offset Limited w/slid Backs, Nt suggested with 19" & 20" wide Push Handles Integral Push Handles Fld Dwn Push Handles w/ 10"- 14" adj height & 8"-10" fixed height w/ standard uphlstery Omit Push Handles 132VU1 132VU2 132VU3 132VU4 132VU12 132VU5 132VU8 132VU9 132VU10 132VU11 132VU13 Military Service Patches US Marines Patch US Army Patch US Navy Patch US Air Frce Patch Cast Guard Patch Purple Heart Patch Purple Heart with Marines Patch Purple Heart with Army Patch Purple Heart with Navy Patch Purple Heart with Air Frce Patch Purple Heart with Cast Guard Patch 132BU1 132BU88 132BU70 132BU71 132JB01 E2611 E2611 Backrest Uphlstery Standard Uphlstery Standard Uphlstery EXO Backrest Tensin Adj Ballistic Nyln *Reference 186BU70 fr billing J3 Back T rder a J3 Back please select Omit Back Uphlstery. See J3 Back Order Frm fr Part #'s. w/freestyleback $ $ $ A JQ01 132JQ02 132JQ03 132JQ04 Telescping Push Handles Range f 13-19" frm sling t handle Telescping Push Handles - Tall (25" frm seat t push handle) Freestyle Backrest Optin 3 Accessries such as head supprts & lateral supprts are nt available with Freestyle backrest. The Freestyle back cmes standard with a small lumbar psitining cmpnent Available with Plastic side guards and limited ranges with Carbn fiber sideguard with fender. Chair Seat depth wil be reduced by 1" with backrest. 132BU89 132BU14 132JB06 132JB07 Backrest Tensin Adj EXO E2611 *Reference XXXBU89 fr billing Omit Back Uphlstery JAY J3 Back E2613 Backrest Tensin Adj 3DX Vented *Reference 186BU71 fr billing Backrest Type JAY J3 Back LT Aluminum E2613 mdel (J3PAXXXYYZZ) JAY J3 Back LT Carbn Fiber mdel (J3CFPAXXXYYZZ) $ Price List $ $ Backrest Optins Telescping Push Handlles have Duble "D" tubing t eliminate rtatin. 132OD5 132A192 Narrw Backrest Inset Backcanes 1" narrwer than selected seat width. with 12" Wide. w/ Aluminum r Carbn Side Guards Backrest Width 14" Backrest Width 16" Backrest Width 18" Backrest Width 20" Backrest Width $80.00 $ $ Backrest Height Medium size backrest nt available in Carbn Fiber. 132QF04 Small 6.5" shell hgt, 9" back height 132QF05 Medium 8" shell hgt, 10.5" back height 132QF06 Tall 9.5" shell hgt, 12" back height Backrest Clr Nt applicable with carbn fiber back r Zebra clr. 132GZ01 Black 132GZ02 Matching Frame- Standard Clrs 132GZ03 Matching Frame- Custm Clr Height Ranges Dim "A" Small 12.0" " Medium 12.0" " Tall 12.0" " Dim "B" 3.0" - 5.5" 1.5" - 5.5" 0.5" - 5.5" Custmer Service: Fax: rders@sunmed.cm Page 5
6 8. ARMREST / SIDEGUARDS Sme limitatins when used with the Angle Adjustable Back in the rear mst setting Increases verall width f chair. Sme interferance may exist w/ padded SA arms Please select a setting, will default t 11" if n selectin is made. at lwest settings Nt available w/height Adjustable Arms 132AA18 E0973 Padded Swing-Away STD (9" t 14") $ SG33 Plastic Standard 9" 10" 11" 12" 13" 14" 132SG29 Plastic Lw Aluminum w/high Push r Pull 132SG35 $ Armrest - Height Adjustable Wheel Lcks 132AA11 132AA29 132AM23 132AM21 132AM24 132AM22 E0973 E0973 Armrest - Padded Swing Away Single Pst Height Adjustable - Std Range 8" - 13". Adjust in 1" increments Single Pst Height Adjustable - Lw Range 6.5" ". Adjust in 1" increments Armpad - Fr Height Adjustable Desk Length (10") Classic Desk Length (10") Cntur Full Length (14") Classic Full Length (14") Cntur $ $ SG36 132SG12 132SG41 Side Guards Aluminum w/ Fender w/ High Push r Pull Wheel Lcks Carbn Fiber w/ High Push r Pull Wheel Lcks Carbn Fiber Lng w/lg Fender w/high Push r Pull Wheel Lcks $ $ $ Side Guard - Clr Optin Available with Aluminum r Aluminum with Fender. Nt applicable t carbn fiber ptins 132GE01 Black 132GE02 Matching Frame- Standard Clrs 132GE03 Matching Frame- Custm Clr 9. KEY OPTIONS AND ACCESSORIES Anti Tips Spke Guards Anti Tip Single Side 12W-14W range, w/xtender r Rear suspensin Only available with Lite spke. w/ Xtender Pwer Assist 132AT37 E0971 Anti Tips (Pair) $ A01 K0065 Quickie Black Spke Guard $ AT14 E0971 Anti Tip Single Side - Flip Up $ A02 K0065 Quickie Clear Spke Guard $ Left Right (Facing frm rear) 132A1 132A2 1321A01 Additinal Pack Accessries Backpack - Adult Backpack - Kids Seat Puch Black Miscellaneus 132A2100 E2207 Crutch Hlder $ A21 Tl Kit 132NP01 Gel Swing Away Pad $45.00 $ Psitining Belt 132A824 E0978 Belt 2" Aircraft Buckle $ A825 E0978 Belt 2" Aircraft Buckle Padded $ A826 E0978 Belt 1.5" Aut Buckle Universal $ A804 Psitining Belt Clamps Only 10. COLOR Standard Frame Clr 132C140 Aztec Gld 132C118 Bead Blast 132C2 Black (Nt avail as base w/zebra) 132C141 Black Cherry 132C10 Black Opal 132C38 Blue Opal 132C36 Candy Blue 132C14 Candy Purple 132C35 Candy Red 132C142 Electric Blue 132C143 Evergreen 132C44 Glssy White 132C126 Glw 132C144 Green Apple 132C147 Ht Sparkle Pink 132C148 Mauve Pink 132C103 Rtbeer 132C114 Sparkle Silver 132C145 Sunrise Orange 132C113 Titanium Clr Paint 132C8 Yellw 132C C C C C C C43 132C42 132C108 Matte Frame Clrs Matte Black Matte Black Cherry Matte Electric Blue Matte Evergreen Matte Purple Custm Frame Clr Desert Camuflage Mssy Oak Camuflage Stars & Stripes Zebra (Chse abve base clr) Std with White unless abve base paint is chsen w/ Blk, Matte Black, Blk Opal, Titanium r Bead Blast) Custmer Service: Fax: rders@sunmed.cm Page 6
7 10. COLOR (CONT) Andized Clr Package Frks, Backcane Bracket, Rear Axle Clamp,and Freestyle munting bracket (if selected). w/ Frg Legs 132EB07 132EB08 132EB13 132EB09 132EB10 Black Blue Gld Lime Green Purple 132EB11 Red 132EB12 Ti Grey Frame Graphics Graphic designs n frnt frame tubes. with transit & Matte Black Cherry. w shrt height frames 1328A24 Blm $ A25 Dragn $ A26 Ghst Flames $ A27 Retr Squares $ A28 Tribal $ Built Fr Me T inquire abut any unique custmizatin fr Quickie prducts, cntact: Phne: (800) , Optin #3, Fax: (800) Cmmnly Requested Optins Include: Swing Away Knee Adductrs fr Oval Tubing One Arm Drive Unilateral Wheel Lcks Seat Pan Caster Pin Lck Grade Aids Active Rigid w/flding Back Spinergy Clr Spkes Custm clr casters (Alum sfrll nly) Lifestyle custm paint package (see website) Blm design Dragn design Ghst Flames design Retr Squares design Tribal design 11. APPENDIX Handrim & Wheel Matrix Wheels Handrims 5 Spke Mag Lite Spke Ultra Lightweight Spinergy Muntain Aluminum Andized 20,22,24 20,22,24,26 22,24,25 22,24,25,26 24 Plastic Cat 20,22,24 22,24 22,24,25,26 24 Natural Fit - Standard Grip 24 Natural Fit - N Thumb Grip 24 Natural Fit - Super Grip 24 Natural Fit LT - Std Grip 24 22,24,25,26 Natural Fit LT - Super Grip Natural Fit LT - N Thumb Grip 24 Surge - Oval w/griptin Strip Surge LT - Oval w/griptin Strip 24 Omit Handrim 20,22,24 Q Grip Neprene Cated 24,25 Spinergy Flex Rim 22,24,25,26 22,24,25,26 24,25 24,25 24 Sunrise Medical (US) LLC 2842 Business Park Ave. Fresn, CA USA Custmer Service: Fax: rders@sunmed.cm Page 7
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a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie 2 Lite January 2018 EIQ2X Submitting fr: Ship
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a Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: ZIP: SUBMITTING FOR: Qute Order Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS Definitin Price a Optin # HCPCS Definitin Price KIDS QUICKIE 2
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a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirmatin Email: Cnfirm Via: Ship T: Attentin: Kids Quickie 2 SE
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a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Ship T: Attentin: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirmatin Email: Cnfirm Via: PO#: ZIP: Kids Quickie
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