R82 Caribou - E0641. Retail Price List/ Order Form. Account #: Purchase Order No.: Date: Caribou Standard Features:
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1 Account #: Purchase Order No.: Date: Contact: R82 Caribou - E0641 Retail Price List/ Order Form Mark For: Bill To: Address: City/State/Zip: Phone: Ship To: Address: City/State/Zip: Phone: Caribou Standard Features: Sizes 1, 2, 3 and 4 4" Locking Castors Contoured Top Plate Height and Angle Adjustable 2-Piece Footrest Tilt: From Vertical to Past Horizontal Caribou Manual Base (A) Caribou Base with 2-Piece Footrest, Yellow (A) 1 $2, FP Caribou Base with 2-Piece Footrest, Red (A) 2 $2, FP Caribou Base with 2-Piece Footrest, Blue (A)* 3 $3, FP Caribou Base with 2-Piece Footrest, Gray (A)* 4 $3, FP (A)* For sz 3 & 4, It is recommended to use the Caribou Base with Power Actuator to ease the tilting. Caribou Power Base (B) Caribou Base with Power Actuator, Yellow (B) 1 $4, ELFP Caribou Base with Power Actuator, Red (B) 2 $4, ELFP Caribou Base with Power Actuator, Blue (B) 3 $4, ELFP Caribou Base with Power Actuator, Gray (B) 4 $5, ELFP Top Pad (C) Top Pad (6" x 7" x 8") (C)* 1 $ Top Pad (7½" x 9" x 9¾") (C)* 2 $ Top Pad (8½" x 10½" x 12¾") (C)* 3 $ Top Pad (9¾" x 12¼" x 15¾") (C)* 4 $ (C)* Required w/ all Caribou Bases; must select one. (D) Head Pad Head Pad (6" x 7" x 8") (D) 1, 2 $ Head Pad (7½" x 9" x 10") (D) 3, 4 $ Extra Cushion (A) Extra Cushion (9¾" x 4¼") (A) One Size $ Extra Cushion (12" x 4") (A) One Size $ Extra Cushion (13¾" x 4") (A) One Size $ Extra Cushion (15¾" x 4") (A) One Size $ Page 1 of 5
2 Pelvic Positioning (A) (B) Pommel (2" x 2¾" x 6" x 6¾) (A) One Size $ Pommel (2" x 2¾" x 6" x 3½") (A) One Size $ Strap for Pommel, sz 1 (Length: 10-12") (B) One Size $ Strap for Pommel, sz 2 (Length: 10½-12½") (B) One Size $ Head Support (A) (B) Head Support No. 1, Black PU One Size $ Head Support No. 2 Black PU One Size $ Head Support No. 3, Black PU One Size $ Head Support No. 4, Black PU One Size $ Anatomic Head Support, Small (A) Small $ Anatomic Head Support Cover, Small (Required) Small $ Anatomic Head Support, Medium (A) Medium $ (C) (D) Anatomic Head Support Cover, Medium (Required) Medium $ Anatomic Head Support, Large (A) Large $ Anatomic Head Support Cover, Large (Required) Large $ Headband System for Anatomic Head Support* One Size $ Add. Headband System for Anatomic Head Support * One Size $ Adj. Head Support, Non-Dynamic, Large Laterals (B) One Size $ Adj. Head Support, Non-Dynamic, Four Laterals (B) One Size $ Adj. Head Support, Non-Dynamic, Two Laterals (B) One Size $ Adj. Head Support, Dynamic, Large Laterals (C) One Size $ Adj. Head Support, Dynamic, Four Laterals (C) One Size $ Adj. Head Support, Dynamic, Two Laterals (C) One Size $ Turtle Bar System (5.1") (D)* Short $ Turtle Bar System (9.8") (D)* Long $ Universal Headrest Mount One Size $ *Do not use while unit is in transit. (D)* Required with Head Support, Anatomic Head Support, Adj. Head Support Non-Dynamic/Dynamic. Foot & Leg Positioning (A) (B) Knee Support, Fixed (A) 1, 2 $ Knee Support, Fixed (A) 3, 4 $ Knee Support, Fixed, Swing-Away (A) 1, 2 $ Knee Support, Fixed, Swing-Away (A) 3, 4 $ Knee Support, Hinged, Fixed (B) 1, 2 $ (C) (D) Knee Support, Hinged, Fixed (B) 3, 4 $ Knee Support, Hinged, Swing-Away (B) 1, 2 $ Knee Support, Hinged, Swing-Away (B) 3, 4 $ Formed Footplates, Set (8½") (C) 1, 2 $ Formed Footplates, Set (9½") (C) 3, 4 $ (E) Heel Support for Parted Foot Support, Set (D) 1, 2 $ Heel Support for Parted Foot Support, Set (D) 3, 4 $ Upholstered Ankle Straps (W: 7¾") (E) 1 $ Upholstered Ankle Straps (W: 9¾") (E) 2 $ Upholstered Ankle Straps (W: 11½") (E) 3 $ Straps for Footrest w/pvc-lock One Size $ Straps for Footrest w/velcro One Size $ Page 2 of 5
3 Trunk Positioning (A) (B) Chest Strap (16½-25") (A) 1, 2 $ Chest Strap (19-30½") (A) 3 $ Chest Strap (15¾-38") (A) 4 $ Cross Straps (16½-19¼") (B) 1 $ Cross Straps (17-21¾") (B) 2 $ Cross Straps (21-27½") (B) 3 $ Cross Straps (24¾-33¾") (B) 4 $ (C) (D) Side Supports, Set (Bar: 5.7", Pad: 5.7" x 3.7") (C) One Size $ Side Supports, Set (Bar: 6.7", Pad: 7.1" x 5.1") (C) One Size $ Side Supports, Set (Bar: 7.9", Pad: 7.1" x 5.1") (C) One Size $ Lateral Support Strap (Strap Length: 10-12½") (D) 1 $ Lateral Support Strap (Strap Length: 12-16") (D) 2 $ Lateral Support Strap (Strap Length: 13½-19¾") (D) 3 $ (E) (F) Shoulder Support, Set (3" x 7½" x 2") (E)* 1 $ Shoulder Support, Set (3¼" x 9½" x 2") (E)* 2 $ Shoulder Support, Set (4" x 12¼" x 2") (E)* 3 $ Shoulder Support, Set (4¼" x 15½" x 2") (E)* 4 $ Wedges for Side Slots (4" x 1.6" x 1"-0.1") (F) 1 $ Wedges for Side Slots (4" x 1½" x 1.6"-0.1") (F) 2 $ Wedges for Side Slots (4" x 2.3" x 1"-0.1") (F) 3 $ (G) (H) Back Support ( 7½" x 6.3" x 5.1") (G) 1, 2 $ Back Support (11.8" x 9.8" x 7.9") (G) 3, 4 $ Upper Arm Supports, Small (4.9" x 13.4") (H) 1, 2 $ Upper Arm Supports, Large (6½" x 20½") (H) 3, 4 $ Cross Vest (4½ x ½ x 11") (I) 0 $ Cross Vest (5 x ½ x 12") (I) 1 $ Cross Vest (5.2 x ½ x 12¾") (I) 2 $ (I) (J) Cross Vest (6¼ x 4¾ x 15¼") (I) 3 $ Cross Vest (7½ x 6¾ x 7") (I) 4 $ Neoprene Vest (7" x 5½" x 4") (J) 1 $ Neoprene Vest (6½" x 9" x 6¾") (J) 2 $ Neoprene Vest (11½" x 7¾" x 7") (J) 3 $ Chest Belt, Upholstered (11¼" x 7½" x 19¼-12") (K) 1 $ Chest Belt, Upholstered (14" x 10¼" x 10¼-12¾") (K) 2 $ (K) (L) Chest Belt, Upholstered (16¼" x 12½" x 10¼-12¾") (K) 3 $ Chest Belt, Upholstered (20¼" x 16" x 11¼-14½") (K) 4 $ Sternum Belt (L) 0 $ Sternum Belt (L) 1 $ Sternum Belt (L) 2 $ Vest (M) 0 $ (M) Vest (M) ¾ $ Vest (M) 1 $ Vest (M) 2 $ Vest (M) 3 $ Vest (M) 4 $ Fix Locks (Required for use of Vests) One Size $ (E)* Shoulder Supports size must match the Top Pad size. Page 3 of 5
4 Accessories Both trays for prone and supine use. (A) (B) Tray, Plastic, with Bowl and Cover (A) 1, 2 $ Tray, Plastic, with Bowl and Cover (A) 3, 4 $ Kit for Low Mount of Trays - For Supine use Only (B) 1, 2, 3 $ KIT Armrests for Plastic Tray (C) All Sizes $ Toybar for Plastic Tray (D) All Sizes $ (C) (D) Grip Handle for Tray (E) 1, 2, 3 $ Push Handle (F) One Size $ U Wrist Cuffs, Each 1 $ Wrist Cuffs, Each 2 $ Wrist Cuffs, Each 3 $ (E) (F) Wrist Cuffs, Each 4 $ For shipping rates, please call PO Box 1739 Matthews, NC Fax: Prices in USD & is subject to change without notice Effective: 10/4/2017 Rev 3 Page 4 of 5
5 Configuration Caribou Top Plate/Shoulder Support Cross Straps/Back Support Transport Fittings Chest Strap Head Support Extra Cushion Hip/Side Support Knee Support/Pommel with Strap Tray A (Total Height) B (Shoulder Height) C (Chest Leg Length) D (Top of Pelvis) D1 (Buttock Height) D2 (Below Knee) E (Chest Width) F (Shoulder Width) G (Pelvis Width) Age Weight Measurements Size 1 Size 2 Size 3 Size 4 Inches Inches Inches Inches Frame Width (G) 20" 22½" 25½" 29¼" Frame Length (H) 29¼" 36" 43¼" 43¼" Height, Vertical (I) 18-22½" 20¾-25¼" 26¾-31" 34¾-39" Height, Horizontal (I1) 27½" 27½" 31½" 31½" Height from Floor to Frame (I2) 5" 5" 5" 5" Basis Plate Width, Top-Bottom(J-J1) 9¾-12½" 11¾-15" 13¾-18" 15¾-21¾" Basis Plate Height (K) 17" 19¾" 25½" 33½" Angling Footplate Angling Weight, without Power 45.2 lbs. 53 lbs lbs lbs. Weight, with Power 49.6 lbs lbs lbs lbs. Max Load 88.2 lbs lbs lbs. 220½ lbs. Approximate Total User Weight 33½-44" 38½-50¾" 49¼-61½" 60¼-72¾" NOTES: Page 5 of 5
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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
Please check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm
EVO AE Order form Dealer 2017 EVO Dealer: Date: Dealer reference / Client name: Order number: Anglikerstrasse 20 CH-5610 Wohlen Phone: +41 56 618 44 11 Fax: +41 56 618 44 10 e-mail: office@levo.ch configuration
The Churchill. A belt positioning backless booster designed for children and adults lbs with special health care needs
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BATTERY BOX BATTERY BOX. Pos Item number Description CommentDescription BATTERY COVER QTY
Title - 1 - Title - 2 - Table Of Contents QUICKIE HULA... 5 BASE FRAME... 5 BATTERY BOX... 5 MAIN SHROUD... 6 FRONT SHROUD... 7 FRONT FRAME... 8 REAR FRAME... 9 BEARING SET... 10 FRONT FORK ASSY... 11
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Dealer Please check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm
EVO CEV Order form Dealer 2017 EVO Dealer: Date: Dealer reference / Client name: Order number: Anglikerstrasse 20 CH-5610 Wohlen Phone: +41 56 618 44 11 Fax: +41 56 618 44 10 e-mail: office@levo.ch configuration
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NEMO VERTICAL Authorised client weight 100 kg + 10 kg additional load ISO-CRASH TESTED
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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:
motivation Product Summary
The Moti-Start Portable Supportive Seat is a locally size adjustable supportive chair. It is intended for use by infants who need extra postural support. It comes semi-assembled and is easy to transport
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: ( )
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
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PAGE 2 BREEZY ELEGANCE
PAGE 2 Category... 1 Product... 1... 5 BASE FRAME... 5 AXLE PARTS... 5 CASTER FORK... 6 ANTI-TIP... 7 WHEEL LOCK... 8 DRUM BRAKE... 9 REAR WHEEL - STANDARD... 10 REAR WHEEL - DRUM BRAKE EQUIPPED... 11
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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
Prime Engineering GRANSTAND II
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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 Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a m e T y
Black -01 Moss green -95 Yellow -99. Heather purple -97. Indicate height. Indicate height. Indicate angle. Indicate height: cm. Indicate height: cm
Cross 5 XL Prescription form 75188K 017-05-08 Reference: Name: Tel: Date: version is marked with The measurements given can vary ±% Short frame Seat width (cm) Seat depth 36-4 (-49*)cm Measured from back
MALTE Posterior Walking Aid
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Seatpan and backrest angles can be adjusted independently, usually with two separate levers
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