Kids Quickie 2 SE (Without Seating) NOVEMBER 2012
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- Douglas Powell
- 5 years ago
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1 a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirmatin Cnfirm Via: Ship T: Attentin: Kids Quickie 2 SE (Withut Seating) NOVEMBER 2012 ZIP: Dealer City: Fax Ship T Phne: ( ) Fax: ( ) Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price KIDS QUICKIE 2 SE W/O SEATING PO#: Address: Ship T City: ADDITIONAL SHIPPING INFORMATION 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. EIZ10 ST: ZIP: 142WM08 E1238 Kids Quickie 2 SE W/O Seating K0005 cding still applies fr EIZ10 with certain sizes $1, FT54 142FT55 Crss Brace w/ Seat Rails 142TO1 Transit System $ Frame Type Uses Rear Side Frame Depth Adj. & Depth Adj. Back Crss Brace with Seat Rails Transit System Incl. Stabilizer Bar. N/A with Swing-Away Strller Handles and Extensin with Crss Brace with Seat Rails. 142C2 142C10 142C38 142C36 142C14 Black 142C35 Candy Red 142C C6 142C C C C C4 142C5 Blue Opal Candy Blue Cpper Frest Green Fuchsia Glw Frame Clr Black Opal Candy Purple Matte Black Matte Green Midnight Purple Pearl Pink 1. FRAMES Standard Frame lbs. Maximum User Weight 142C C C C11 142C8 Sparkle Silver Txic Green Yellw Custm Frame Clr 142C43 Mssy Oak Camuflage 142C42 142C W2 Stars & Stripes 142W3 12" 142W4 13" 142W5 142W7 142W9 Frame Clr - Cntinued Rt Beer Titanium Clr Paint Zebra (Chse abve base clr) Std with White unless abve base paint is chsen. NA w/ Black Frame Width 11" (By Uphlstery) (Avail. w/crss Brace w/ Seat Rails Only) 14" 142W6 15" 16" 142W8 17" (Avail. w/crss Brace w/ Seat Rails Only) 18" (Avail. w/crss Brace w/ Seat Rails Only) Custmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC REV. I Page 1
2 142FL1 Kids Frame (10"-16" Depth) 142FD3 10" Frame Depth 142FD4 11" Frame Depth 142FD5 13" Frame Depth 142FD6 15" Frame Depth 142FD7 16" Frame Depth 142FL9 Regular Frame (12"-18" Depth) 142FD3 12" Frame Depth 142FD4 13" Frame Depth 142FD 15" Frame Depth 142FD8 17" Frame Depth 142FD9 18" Frame Depth Lng Frame (14"-20" Depth) 142FD5 14" Frame Depth 142FD6 15" Frame Depth 142FD8 17" Frame Depth 142FD10 19" Frame Depth 142FD11 20" Frame Depth FRAME DEPTH AND BACK POST LOCATION Chse 1 r 2 1. Frame Depth and Back Pst Lcatin W/O Seat Rail 2. Frame Depth and Back Pst Lcatin With Seat Rail CHOOSE 1 OR 2 Frame Length 142FL1 Kids STD 142FL9 Regular 142FL18 Lng Seat Rail Length (Sling Nt Included) 142SN05 10" 142SN06 11" 142SN07 12" 142SN08 13" 142SN09 14" 142SN10 15" 142SN11 16" 142SN12 17" 142SN13 18" Back Pst Lcatin 142BL14 1" Offset Frm Seat Rail 142BL15 2" Offset Frm Seat Rail DEPTH ADJUSTABLE BACK and JAY Strller Handle (Height) 142BP27 Depth Adj. Back Pst Standard STD 142BP28 Depth Adj. Back Pst Medium 142BP29 Depth Adj. Back Pst Tall Strller Handle Optins 142BP33 Swing Away Strller Handles $ 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. 142JC20 Name / Part # Width: JAY Cushins (Optinal) JAY Bundled Cushin Depth: Price List ARMRESTS 142AA3 Flip Up STD 142AA9 E0973 Ht Adj. Kids $ AA1 E0973 Ht. Adj. Lcking Flip Up 142AM1 Desk Length (10") 142AA7 E0973 Ht/Length Adj. Lcking Flip Up $ AM2 Full Length (14") 142AM1 Desk Length (10") 142AA8 E0973 Ht/Length Adj. Adult $ AM2 Full Length (14") 142AM1 Desk Length (10") 142AM9 Fam Shrt 142AM2 Full Length (14") 142AM10 Fam Lng 142AA14 Omit Armrest Custmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC REV. I Page 2
3 Hanger 142F3 142E1 Shrt (see matrix fr length) 142E4 Medium (see matrix fr length) 142E5 Lng (see matrix fr length) 142E12 Shrt ELR (ELR nly) 142E16 142F1 Cmpsite Ftplate (12"-16"w) STD FOOTRESTS Chse 1 r 2 1. Hanger Type (Munt With Extensin Tube) 2. Hanger Type (Direct Munt 142H1 60 Swing-Away Hanger STD 1424H14 E0990 Extensin Tube (Required fr Optin 1) Ftplate K0037 Elevating Hanger (Only avail. w/ alum. Ftplates r angle adj. Available n 14"-18" frame widths. N/A w/ lcking angle adj. ftplates r shrt ext. tubes.) High Munt NA elevating leg rests. Only avail. w/ adult r kids angle adj. ftplates. 142F4 Kids Angle Adj. Ftplate 142E15 Lng ELR (ELR nly) $ Adult Angle Adj. Ftplate (12"-16"w) $ CHOOSE 1 OR 2 Hanger 142H7 142H8 142H6 Extensins (Optinal) 1.42E23 142E24 Ftplate Type 1.42E23 142E24 70 Swing Away Hangers Frnt Munt (Only avail. w/ Kids r Adult Angle Adj. r 90 ftbard ftplates) 80 Swing Away Hangers Frnt Munt (Only avail. w/ Kids r Adult Angle Adj. r 90 ftbard ftplates) 70 Swing Away Hangers (Only avail. w/ Kids r Adult Angle Adj. r 90 ftbard ftplates) 2" Extensins (n/a w/90 hangers & elevating leg rests) 4" Extensins (n/a w/90 hangers & elevating leg rests) Kids Angle Adjustable Ftplate (10" - 16" W) Adult Angle Adjustable Ftplate (Available n 12" - 16" W) $ $ F48 Platfrm Flip Up Ftplate (n/a with shrt ext. tubes. Only avail. With and 70 V) $ F5 Ftrest Optins Aluminum Ftplate Available w/ ELRs 142HL9 E0951 Heel Lps $ HL8 Impact Guard K0038 Leg Straps $ A54 K0038 Extra Leg Strap $ IG2 Neprene (Only avail. With and 70 V) CASTERS 142CW3 Caster Wheels 4" Plyurethane $ CW5 5" Lw Prfile Plyurethane 142CW6 5" Sft Rll Semi Pneumatic 142CW33 142CW31 142CW7 6" Pneumatic (Requires selectin f Caster Tire Tube/Insert) 142CW34 6" Plyurethane STD 142CW35 142CW21 142CW32 4" Micr Lighted 5" x 1.5" Semi Pneumatic (nly avail. fr use in bttm frk hles) 6" x 1.5" Semi Pneumatic (nly avail. fr use in bttm frk hles) 8" Pneumatic (Nt avail. w/ 90 elevating leg rests. Nt avail. w/kids frame length. Requires selectin f Caster Tire Tube/Insert) 8" Plyurethane (Nt avail. w/ 90 elevating leg rests r w/kids frame length.) $ CW39 142CW36 Caster Wheels - Cntinued 142OM Omit Caster Wheels Caster Tire Tube/Insert Requires a selectin f 6", 8" r 8"x2" Pneumatic Tire. 142CZ2 K0064 8" x 1.5" Semi Pneumatic (nly avail. fr use in bttm frk hles) 8" x 2" Pneumatic (Nt avail. w/ 90 elevating leg rests. Nt avail. w/kids frame length. Requires selectin f Caster Tire Tube/Insert) Airless Insert (Only avail. With 8"x2" Pneumatic) $ $ CZ1 Caster Tube (all sizes) $20.00 Caster Optins 142CS5 3/4" Lnger Frk Stem Blt 142CS10 1-1/2" Lnger Frk Stem Blt 142CS3 K0073 Caster Pin Lcks $ Custmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC REV. I Page 3
4 AXLE AND WHEELS 142AL2 Standard Adjustable Requires a selectin f Pneumatic 142AL71 E0959 Amputee Adjustable 142RZ2 E2213 Pneumatic Airless Insert $ RW3 20" Mag 142RW75 142RW54 Omit Rear Wheel Type 22" Spke 24" Spke Axle 142AX1 Quick Release STD 142AX11 Quad Quick Release $90.00 Anti-Tip 142AT6 E0971 Rear Anti-Tip $ RW74 20" Spke 142RW8 22" Mag 142RW1 24" Mag 142RT1 E2211 E2212 Axle Plate Rear Wheel Tire Pneumatic (Requires the selectin f Rear Wheel Tire/Insert) 142RT29 E2218 Full Plyurethane (avail w/mag nly) $50.00 $ RT1 E2211 E2212 Rear Wheel Tire Tube/Insert Pneumatic Tube Hand rim 142HR1 Aluminum Andized 142HR4 Plastic Cated $ HR7 Omit Wheel Lck 142WL1 High Munt Push 142WL2 High Munt Pull Extensin Handle 142EH1 E0961 6" Pair Grade Aid Requires a selectin f Rear Wheel Tire/Insert 142GA1 E0974 Grade Aid $ ACCESSORIES Backpack Psitining Belt 142A1 Utility Pack - Black 142A141 E0978 Belt 1.5" Aut Buckle w/clamps $ A2 Kids Black Backpack - Zippie $ A117 E0978 Belt 2" Aircraft Buckle w/clamps $ A118 K0108 Belt 2" Aircraft Buckle w/clamps $ A112 E0978 1" Dual Pull Side Squeeze Pad w /Clmp Seat Puch 142A814 E0978 1" Cmfrt Fit APB5116 $ A8 Black $45.00 Spke Guard 142A23 K0065 Black $ Crutch Hlder 142A24 K0065 Clear $ A49 E2207 Crutch Hlder $ Upper Extremity Supprt Tray Miscellaneus 142A29 E0950 X-Small (Suggested 10"-12") 142A83 Tl Kit $ A30 E0950 Small (Suggested 13"-14") Side Guard 142A31 E0950 Medium (Suggested 15"-17") Nt available with height adj. flip back armrests 142SG4 K0108 Plastic Kids $ A32 E0950 Large (Suggested 18"-20") 142SG3 K0108 Plastic Regular $ Custmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC REV. I Page 4
5 Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC REV. I Page 5
Kids Quickie 2 SE (Without Seating) NOVEMBER 2012
a Mark Fr: Submitting fr: Qute Order ST: Dealer Phne: ( ) Address: Fax: ( ) ZIP: Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price KIDS QUICKIE 2 SE W/O
Kids Quickie 2 SE November 2012
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
Kids Quickie 2 SE January 2018 EIZ10
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
Zippie 2 January 2018 EIZ2
Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: Mark Fr: ZIP: Zippie 2 January 208 EIZ2 SUBMITTING FOR: Qute Order Fax Email Ship T Phne:
Zippie TS SE November 2012 EIZ1A
Zippie TS SE Nvember 2012 EIZ1A Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer City: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirm Via: Mark Fr: ZIP: Dealer Address: SUBMITTING FOR: Qute Order Ship
Quickie 2HP January 2017
a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie 2HP January 2017 EIHP Qute Fax Email Ship T
Quickie 2HP January 2018
a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie 2HP January 2018 EIHP Qute Fax Email Ship T
Zippie GS SE January 2019 EIZGS
Zippie GS SE January 209 EIZGS Date: SUBMITTING FOR: Qute Order Dealer Acct #: Dealer: PO#: Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: ST: ZIP: Address: Dealer Phne: ( ) Fax: ( ) Address:
Zippie GS January 2019 EIZGS
Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: Mark Fr: ZIP: Zippie GS January 09 EIZGS SUBMITTING FOR: Qute Order Fax Email Ship T Phne:
Zippie TS January 2019 EIZ1A
a ST: Dealer Phne: ( ) Fax: ( ) 187WM63 Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: Cnfirm Via: Mark Fr: 187WM65 187WM64 187WM66 ZIP: SUBMITTING FOR: Qute Order Fax Email Ship
Zippie TS SE January 2019 EIZ1A
a ST: Dealer Phne: ( ) Fax: ( ) ZIP: SUBMITTING FOR: Qute Order Fax Email Ship T Phne: ( ) Fax: ( ) Flding Grwing Zippie TS SE Withut Seating 187WM67 E1234 Transit Optinal $2,575 True Fit Nt Included Date:
Zippie TS SE January 2018 EIZ1A
a ST: Dealer Phne: ( ) Fax: ( ) ZIP: SUBMITTING FOR: Qute Order Fax Email Ship T Phne: ( ) Fax: ( ) Flding Grwing Zippie TS SE Withut Seating 187WM67 E1234 Transit Optinal $2,575 True Fit Nt Included Date:
Quickie LXI/LX. January 2019 EILXI/EILX. Address: Ship To City: o Fax o
a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie LXI/LX January 2019 EILXI/EILX Submitting fr:
Quickie QX February 2019
a Mark Fr: Dealer Acct #: Dealer Cntact: Dealer Address: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: Optin # Date: Dealer: Dealer City: ZIP: Quickie QX February 2019 EIF6 Fax Email Ship
Quickie IRIS SE. November 2012
Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: PO#: ZIP: Quickie IRIS SE Nvember 2012 EIZ4-2 Submitting fr:
Quickie 2HP July 2018
Quickie 2HP July 2018 EIHP Mark Fr: Submitting fr: Qute Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: PV: PC: Address:
Quickie QXi January 2018
a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: Optin # ZIP: EIF6 Fax Email Ship T Phne: ( ) Fax: ( ) Definitin
Quickie QXi January 2019
Quickie QXi SUBMIT January 2019 EIF6 Mark Fr: Submitting fr: Date: PO#: Qute Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: Dealer
Quickie QXi July 2018
Quickie QXi July 2018 EIF6 Mark Fr: Submitting fr: Qute Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: PV: PC: Address:
Quickie Qxi November 2016
Quickie Qxi Nvember 2016 EIF6 Mark Fr: Submitting fr: Date: PO#: Qute Order Dealer Acct #: ADDITIONAL SHIPPING INFORMATION Dealer: Dealer Cntact: Ship T: MEDmbility Reference Only Dealer Address: Attentin:
Quickie QRi January 2019
a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie QRi January 2019 EIR
Quickie 2 Lite. January 2018 EIQ2X
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
Quickie 2 Lite. January 2019 EIQ2X
Quickie 2 Lite January 2019 EIQ2X a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Qute Fax Email Ship
Zippie X'Cape March 2018 EIFZ1
Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) ZIP: Ship T City: SUBMITTING FOR: Qute Order Cnfirm Via: Fax Email Ship T Phne: ( ) Fax: ( ) Mark
Zippie X'Cape January 2019 EIFZ1
Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) ZIP: Ship T City: SUBMITTING FOR: Qute Order Cnfirm Via: Fax Email Ship T Phne: ( ) Fax: ( ) Mark
Quickie Q7 Active Rigid November 2012
a Mark Submitting Fr: fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirmatin Email: Cnfirm Via: PO#: Quickie Q7 Active
Quickie Q7 Adjustable November 2012
a Mark Submitting Fr: fr: Qute Order Dealer Acct #: ST: Dealer Phne: ( ) Address: Fax: ( ) ZIP: Cnfirmatin Email: Ship T City: ST: Cnfirm Via: Fax Email Ship T Phne: ( ) Fax: ( ) Optin # Date: Dealer:
Zippie Zone January 2019 EIRZ1
Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: Mark Fr: ZIP: Zippie Zne January 2019 EIRZ1 SUBMITTING F: Qute Order Fax Email Ship T
Quickie Q7 Active Rigid January 2018
a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Fax Email Ship T Phne: ( )
Quickie Q7 Adjustable December 2012
Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Quickie Q7 Adjustable December 2012 ZIP: Ship T: Attentin: Address:
Quickie IRIS March 2015
a Mark Fr: Dealer Acct #: Dealer Cntact: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Optin # 183FS24 ZIP: Quickie IRIS March 2015 EIZ4-2 Submitting fr: Qute Order Fax Email Ship T Phne: ( ) Fax: ( ) a 1.
Quickie SR45 January 2018
Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie SR45 January 2018 Address: Address: Ship T City:
Quickie 2 EIQ2 MASS MASS PLAQUE NO. P
Quickie 2 EIQ2 MASS 2009 - MASS PLAQUE NO. P ACCOUNT #: SHIP TO: DATE: NAME: P.O. #: ADDRESS: BUYER: CITY/ STATE: MARKED FOR: POST CODE: PHONE NUMBER: BASE MODEL 113 kgs weight capacity 184WM58 Quickie
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: ( )
Quickie Q7 Adjustable August 2015
Quickie Q7 Adjustable SUBMIT August 2015 EIR4 Mark Fr: Submitting fr: Date: PO#: Qute Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer
Quickie 7 RS October 2015
a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: Optin # HCPCS ZIP: Quickie 7 RS
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
Zippie IRIS SE January 2019 EIZ5A
Zippie IRIS SE January 2019 EIZ5A Date: SUBMITTING FOR: Qute Order Dealer Acct #: Dealer: PO#: Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: ST: ZIP: Address: Dealer Phne: ( ) Fax: ( )
September 2016 EIR11 ADDITIONAL SHIPPING INFORMATION
a Mark Fr: Submitting fr: Qute Order Dealer Cntact: Dealer Address: ST: Dealer Phne: ( ) Fax: ( ) Optin # Date: Dealer Acct #: Dealer: Dealer City: Cnfirmatin Email: Cnfirm Via: ZIP: Fax Email Ship T Phne:
September 2017 EIQ2X. Mark For: Submitting for: o Quote
Quickie 2 September 2017 EIQ2X a Mark Fr: Submitting fr: Qute ST: Dealer Phne: ( ) Fax: ( ) ZIP: Cnfirmatin Email: Ship T City: ST: ZIP: Cnfirm Via: Fax Email Ship T Phne: ( ) Fax: ( ) The HCPCS CODES
Quickie 7 RS March 2018
a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: Optin # HCPCS ZIP: Fax Email Ship
Quickie Q7 Adjustable January 2018
Quickie Q7 Adjustable SUBMIT January 2018 EIR4 Mark Fr: Submitting fr: Date: PO#: Qute Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer
Quickie Xenon 2 April 2018 EIX2
a Mark Fr: ST: Dealer Phne: ( ) Fax: ( ) ZIP: Qute Fax Email Ship T Phne: ( ) Fax: ( ) Base Mdel Frame Angle Fr sizes 14" r less please use HCPCS E1236 Fixed Frnt & Dual tube nly. See FIGURE 2 107WM96
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:
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
Quickie Xenon 2 January 2019 EIX2
a Dealer Acct #: ST: Dealer Phne: ( ) Fax: ( ) ZIP: Qute Fax Email Ship T Phne: ( ) Fax: ( ) Base Mdel Frame Angle Fr sizes 14" r less please use HCPCS E1236 Fixed Frnt & Dual tube nly. See FIGURE 2 107WM96
Quickie 7 R October 2015
Quickie 7 R Octber 2015 EIR11 Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: PO#: Dealer: Dealer Cntact: ADDITIONAL SHIPPING INFORMATION Ship T: Dealer Address: Attentin: Dealer City: ST: ZIP:
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:
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
Quickie 7 R. January 2019 EIR11. ADDITIONAL SHIPPING INFORMATION Dealer Contact:
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:
Quickie 7 R March 2018
Quickie 7 R March 2018 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:
Quickie 7 R. January 2018 EIR11. ADDITIONAL SHIPPING INFORMATION Dealer Contact:
Quickie 7 R January 2018 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:
Quickie 2 January 2014
Mark For: Submitting for: Quote Order Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: ZIP: Dealer Phone: ( ) Fax: ( ) Address: Confirmation Email: Ship To City: ST: ZIP: Confirm
Quickie IRIS March 2016
a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: Optin # HCPCS ZIP: Quickie IRIS March 2016 Qute Fax Email
Quickie 7 R. July 2018 EIR11. ADDITIONAL SHIPPING INFORMATION Dealer Contact: Option # 1. FRAME 132FF1 132FF2 132FF3. o o o $ $ $150.
Quickie 7 R July 2018 EIR11 Mark Fr: Submitting fr: Qute Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: PV: PC: Address:
Quickie 2 EIQ2N Effective April 2011
Quickie 2 EIQ2N Effective April 2011 ACCOUNT #: SHIP TO: DATE: NAME: P.O. #: ADDRESS: BUYER: CITY/ STATE: MARKED FOR: ZIP CODE: PHONE NUMBER: The HCPCS codes provided are based on code verification by
ZIPPIE IRIS (Transit Included) EIZ5A
ZIPPIE IRIS (Transit Included) EIZ5A MASS QLD ORDER FORM SUMMARY PAGE Effective: January, 2014 ORDERING INFORMATION: (02) 9678 6600 Fax: (02) 9678 6655 Email:orders@sunrisemedical.com.au Date: Sales Rep:
Zippie Voyage January 2019 EIZ16
ST: Dealer Phne: ( ) Fax: ( ) ZIP: SUBMITTING F: Qute Order a Optin # HCPCS Definitin Price a Optin # HCPCS Definitin Price 1. FRAME STYLE Designed in cnjunctin with Baby Jgger allwing their patented quick
Quickie GTX Swing-Away FSS NET ORDER FORM/PRICE LIST (SIN F-1)
Account No: Drop Ship/Ship To: Date: Name: P.O. #: Address: Buyer: City: State: Marked For: Zip Code: Phone Number: Seat Depth (Continued) 163SD10 17" NC 163SD11 18" NC 163SD12 19" 1 NC Frame Style 163SD13
Zippie Voyage January 2018 EIZ16
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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: Optin # ZIP: Quickie IRIS April 2017 EIZ4-2 Qute Fax Email
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Mark Fr: Submitting fr: Qute Order Dealer Cntact: Dealer Dealer Phne: ( ) Fax: ( ) JAY J3 Psterir (PA) Backrest E2613 (
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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.
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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
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