ATP MOBILITY ASSESSMENT FORM
|
|
|
- Melinda Logan
- 5 years ago
- Views:
Transcription
1 ATP MOBILITY ASSESSMENT FORM Name: Date: Address: City: State: Zip: DOB: Weight: Height: Gender: PLACE OF SERVICE: Assisted Living Home SNF : Physician: NPI: Address: City: State: Zip: Primary Insurance: Policy: Secondary Insurance: Policy: Diagnosis: Skin Integrity: CURRENT MOBILITY DEVICE Cane Crutches Walker Manual Wheelchair POV/Scooter Power Wheelchair Make/Model: S/N: Seat Height: Width: Depth: Back Height: Seating System: Problems noted with current seating and/or mobility device: WHEELCHAIR USAGE AND ENVIRONMENTAL / ACCESSIBILITY CONSIDERATIONS Where used: Home School Work Hours home alone: All day >12 Hrs >8 Hrs >4 Hrs >2 Hrs <2 Hrs Total usage: All day >12 Hrs >8 Hrs >2 Hrs <2 Hrs Minimal Transfers: Ind. Assist. Stand. Lateral Slide Dep. /Device Home entrance: # Stories: # Stairs: Ramp: Floor coverings: Transportation: Public Bus Van Auto Airline Driver in w/c Transfer to driver seat Passenger in w/c Transfer to passenger seat Page 1 of 7
2 What are your mobility limitations an how does this affect your ability to move throughout your home to participate in your activities of daily living (toileting, feeding, dressing, grooming and bathing)? Toileting: Grooming: Bathing: Dressing: Feeding: KEY: 1 = Increased time 2 = Distance 3 = Balance 4 = Safety 5 = Pain 6 = Shortness of Breath Have you tried or do you use a cane or walker in your home? Yes No Can you walk without the assistance of a caregiver? Yes No What distance are you able to walk without rest? What physically limits your ability to walk or walk further? Non-functional leg(s) Loss of lower extremity Weakness in leg(s) Extremity pain Back pain Balance / Fear of falling Shortness of breath Chest pain What other factors limit your ability to walk or walk further? Cannot hold equipment Cannot lift equipment Distance to room Floor covering(s) Have you tried or do you use a manual wheelchair in your home? Yes No Manual Wheelchair Make: Model: Rental/Trial Customer Owned Can you self-propel without the assistance of a caregiver? Yes No What distance are you able to self-propel without rest? What physically limits your ability to self-propel / self-propel further? Non-functional arm(s) Non-functional Leg(s) Weakness in arm(s) Weakness in leg(s) Pain in arm(s) Pain in leg(s) Shortness of breath Chest Pain What limits your ability to self-propel / self-propel further? Cannot grip handrim Cannot repeat motion Distance to room(s) Floor covering(s) Page 2 of 7
3 Manual Wheelchair Base Trialed: Frame Options / Accessories Tilt in space Adjustable angle back Manual reclining back Seat Width Seat Depth Arm Options / Accessories Fixed height arms Adjustable height arms Reclining arms Footrest / Legrest Options / Accessories Foot platform Swing-away footrest Adj. angle footplate(s) Large footplate Heel loops Calf / Leg strap Manual ELR s Articulating ELR s Wheel Options / Accessories Adjustable axle Wheel lock extensions Grade aids Coated handrim(s) Projection handrim(s) Spoke protectors Flat free inserts Shock absorber(s) Amputee adapter Miscellaneous Options / Accessories Pelvic belt Anti-tippers Vent tray O2 Tank holder IV Hanger Cane / Crutch holder Page 3 of 7
4 Have you tried, or do you use a POV (Scooter) in your home? Yes No Are you able to safely maneuver a POV (Scooter) in your home? Yes No SCOOTER / POV Make: Model: Trial Customer Owned Demonstrated the ability to safely operate all components of the scooter / POV Yes No Demonstrated the ability to safely transfer to/from the scooter / POV Yes No Demonstrated improved ability to perform MRADL's with the scooter / POV Yes No What physically limits your ability to operate a scooter / POV? Non-functional arm(s) Weakness in arm(s) Pain Limited range of motion Limited balance What other factors limit your ability to use a scooter / POV? Cannot grip tiller Turning radius Seating required Have you tried, or do you use a power wheelchair in your home? Yes No Are you able to safely maneuver a power wheelchair in your home? Yes No POWER WHEELCHAIR Make: Model: Trial Customer Owned Demonstrated the ability to safely operate a power wheelchair Yes No Demonstrated the ability to transfer to/from a power wheelchair Yes No Demonstrated improved ability to perform MRADL's with the recommenced PWC Yes No What physically limits your ability to operate a power wheelchair? Non-functional arm(s)* Spasticity* Incoordination/Tremors* Weakness-hand/arm(s)* Limited range of motion Pain* Limited balance* * What other factors limit your ability to use a power wheelchair? Cannot grip control* Special seating req'd* Power seat functions* * * * * An OT / PT Seating & Wheeled Mobility Evaluation is required Page 4 of 7
5 Power Wheelchair Base Trialed: Power Seating Functions Power Tilt in Space Power Reclining Back Power Seat Elevator Power Stand System 1 Pwr function thru drive control 2+ Pwr functions thru drive control Frame Options / Accessories Seat Width " Seat Depth " Arm Options / Accessories Fixed Height Arms Adjustable Height Arms Reclining Arms Footrest / Legrest Options / Accessories Foot Platform Swing-away Footrest Manual ELR's Power ELR's Power Foot Platform Adj. Angle Footplate(s) Large Footplate(s) Heel Loops Calf / Leg Strap Wheel Options / Accessories Flat Free Inserts Shock Absorber(s) Battery, Electronics & Drive Control Options Swing-away Mount Joystick Alternative Drive Control Gel Cell Batteries Miscellaneous Options / Accessories Pelvic Belt Vent Tray O2 Tank Holder IV Hanger Cane/Crutch Holder Page 5 of 7
6 MEASUREMENTS LEFT RIGHT LEFT RIGHT A Max. sitting height J Forearm depth B Occiput height K Elbow height C Head width L Thigh depth D Shoulder width M PSIS height E Chest width N Ischial depth F Trunk depth O Hip width G Shoulder height P Lower leg length H Axilla height Q Foot depth I Scapular height R A C B F D G/R G/L J/R J/L H/L E H/R M/R M/L K/R K/L I/L O* I/R N/R L/R N/L L/L Q/R P/R Q/L P/L Page 6 of 7
7 Seating and Positioning Seat Cushion / Support Solid Seat Back Cushion / Support Positioning Accessories Headrest / Support Multi-axis, Removable and/or Swing-away Headrest Hardware Lateral Trunk Support(s) Shoulder Harness/Chest Strap Lateral Thigh Support(s) Medial Thigh Support Swing-away / Flip-down Bracket(s) Arm Trough 1/2 Tray UE Support Full Tray UE Support Residual Limb Support Foot Positioners Equipment Recommendation: See Order Form(s) I acknowledge that I have reviewed this entire document, agree with the information contained herein and that the answers I have provided are accurate and truthful. I am able to safely / independently operate the recommended equipment in my home and am willing to use it routinely I am not able to safely or independently use the recommended equipment within my home I do not wish to use the recommenced equipment in my home and require it for use in the community only Client Signature: Date: Name of Representative completing the Assessment: ATP Certification #: Signature: Date: Page 7 of 7
All Durable Medical Equipment Providers. Subject: Medicaid Coverage of K Codes for Power Mobility Devices
INDIANA HEALTH COVERAGE PROGRAMS P R O V I D E R B U L L E T I N B T 2 0 0 8 3 2 J U L Y 1 7, 2 0 0 8 To: All Durable Medical Equipment Providers Subject: Medicaid Coverage of K s for Power Mobility Devices
Wheelchairs: Manual or Power Operated. and Power Operated Vehicles (POV)/Scooters MP9111
MP9111 Covered Service: Prior Authorization Required: Additional Information: Yes when meets criteria below Yes None Prevea360 Health Plan Medical Policy: Manual Wheelchair 1.0 Manual wheelchairs require
MEDICAL POLICY Power Mobility Devices
POLICY........ PG-0284 EFFECTIVE......07/15/09 LAST REVIEW... 04/11/17 MEDICAL POLICY Power Mobility Devices GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated
MEDIchair Northern BC nd Avenue Prince George, British Columbia V2L 3A6 Toll Free
MEDIchair Northern BC 849 2 nd Avenue Prince George, British Columbia V2L 3A6 Toll Free 1-800-330-2772 BC Ministry of Health A Cheat Sheet for Clinicians Included Features for a Basic Wheelchair, Basic
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
Velocity Order Form. Dealer Information Dealer Name ATP Account Number Phone Fax Date PO# Ship to Address City State Zip
1-800-963-7487 Fax: 239-772-3252 Velocity Order Form Dealer Information Dealer Name ATP Account Number Phone Fax E-Mail Date PO# Ship to Address City State Zip Client Information Weight Height Seat-to-Floor
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....
C300 Corpus Tilt. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the
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:
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Canada AADL CAT # 151 Effective 10/01/2018 Company: Account Number: Date: q Quote q PO Number:
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.
wheelchairs aspire for... mobility comfort style LITE TRANSIT RANGE Aspire EVOKE Aspire EVOKE HD
EVOKE & EVOKE HD TRANSIT ASSIST wheelchairs aspire for... mobility comfort style LITE LITE TRANSIT RELAX RANGE Aspire EVOKE Aspire EVOKE HD Aspire ASSIST Aspire TRANSIT Aspire RELAX Aspire LITE Aspire
Wheelchair Options/Accessories
Wheelchair Options/Accessories Adopted from National Government Services website For any item to be covered by The Health Plan, it must: 1. Be eligible for a defined Medicare or The Health Plan benefit
FUZE T50. Order Form USA. Please send your completed order form by to or by fax to
Page 1 of 5 Purchase Order Tag Dealer/Organization Name Purchaser Name and Contact Information Mailing Address Shipping Address Please send your completed order form by email to info@pdgmobility.com or
Phone: Nov-17
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
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
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
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
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
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
Standard Base Price: 618
Manual Wheelchair Retail Prescription Form ACTION4NGHD11112016 Tel: 01656 776222 Fax: 01656 776220 JAN 2017 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref: Contact
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 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
M1 - NPO. Dealer Information. Client Information. Client Measurements
Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified
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:
Convaid Trekker 2 - HCPCS E1234 Retail Price List / Order Form
Account #: Contact: 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 TR12 & TR14
BENTLEY. 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. 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
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
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.
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
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
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
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:
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
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.
ALS Society of NB and NS - Equipment Loan Form
The ALS Society of New Brunswick and Nova Scotia is a non-profit organization and is not funded by any level of government. Completion of this form will assist our staff in providing the most appropriate
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:
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
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)
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
Aquatec Ocean Family. Ocean Family. Aquatec
The Ocean series of shower commode chairs offers a flexible, modular solution for a wide range of clients. The range consists of transit, self-propel, tilt in space as well as powered tilt and recline
USA Parts List FUZE T50
USA Parts List FUZE T50 Effective January 1, 2018. Prices in U.S. Dollars. Prices and descriptions contained in this manual are subject to change without prior notice. Fuze T50 Frame-Seat Pan Cross Bar
WHEELCHAIRS. aspire for... mobility comfort style OUR RANGE The Aspire EVOKE.
EVOKE ASSIST WHEELCHAIRS aspire for... mobility comfort style LITE TRANSIT RELAX OUR RANGE The Aspire EVOKE The Aspire ASSIST The Aspire TRANSIT The Aspire RELAX The Aspire LITE www.aspirewheelchairs.com.au
Accessories brochure
Accessories brochure NEW The Invacare Rea Passive range, with its tilt and recline chairs is compatible with a wide variety of accessories, giving users the opportunity to achieve an optimal fit, and greater
Traxx 3 & Atigra 2 Script Form
Traxx 3 & Atigra 2 Script Form Client Information Address Therapist Information Organisation Email Phone Height Weight Funding Source Salesperson Information Company Traxx 3 Atigra 2 Standard Features
Shower commode chairs
Ocean, Ocean XL, Ocean Vip, Ocean ual Vip, The Ocean series of shower commode chairs offers the right model for all demands. www.clarkehealthcare.com 888-347-4537 17 Ocean Stable, stainless steel frame
18 Wide. MRI Transport Wheelchairs. Overall Width: 26 Wheelchair, With Fixed Footrest. Specifications:
MRI Transport Wheelchairs 18 Wide Overall Width: 26 Wheelchair, With Fixed Footrest Removable Full Length Padded Arms Fixed Footrests Seat To Floor Height: 19 1/4 Seat Width: 18 Overall Width: 26 Overall
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
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:
ORDER FORM EIPW25. with CAPTAIN'S SEAT. Print pages 1-10 to exclude pictures. Buyer State Zip
ORDER FORM Print pages 1-10 to exclude pictures. with CAPTAIN'S SEAT EIPW25 Customer Account # Date PO# Ship To Name Address City Buyer State Zip Mark For Phone Client Measurements a) Top of head to seat
4.2 HELIO KIDS MODEL. Ultralight Folding Carbon Fiber HELIO KIDS Wheelchair Including angle & depth adjustable back (79 kg lbs weight capacity)
519, J-Oswald Forest, suite 101 Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.450 588-6555 1 866 650-6555 F.450 588-0200 www.motioncomposites.com Account : PO : Vendor : CUSTOM TECHNOLOGIES LIMITED Date
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
Invacare Action 3 Junior Large Retail Max User Weight 80Kg (12.5 stone) Standard Base Price: 539 * Configurations may vary to the image shown
Manual Wheelchair Retail Prescription Form ACTION3JUNIORLARGE15112017 Tel: 01656 776222 Fax: 01656 776220 JAN 2018 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer Ref:
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
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 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
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
Invacare Action 3 Junior Basic RETAIL Max User Weight 80Kg (12.5 stone)
Manual Wheelchair Retail Prescription Form ACTION3JUNIORBASIC05122018 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer
BREEZY EC WHEELCHAIRS. The best combination of durability, selection and value.
BREEZY EC WHEELCHAIRS The best combination of durability, selection and value. Breezy EC 2000 A quality wheelchair with options offering the flexibility to accommodate a variety of users. Standard Features
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 #: Address: ST: ZIP:
May 2014 Kids FAST Order Form Maximum Weight Capacity 80 lbs. 12"Wx14.5"Dx19.5"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
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:
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
Aquatec. Ocean Family. Flexible, modular shower chair commode solutions
Aquatec Ocean Family Flexible, modular shower chair commode solutions A range of high quality, modular, stainless steel shower chair commodes that are designed to support a wide range of clients and conditions.
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
Order form LEVO LAE 2011/1
Seat height 48 Seat height 51 Seat height 54 Seat height 57 Order form LEVO LAE 2011/1 Please answer the following questions exactly and consider the indications.the exact measurement within the pictograms
V6 & X8. Table of Contents
V6 & X8 Table of Contents Page 2. Base Page 2. Frame Color Page 3. Seating System Page 3. Reduced Drive Capability Page 4. Power Seat Options: Seat Function Control Page 4. Seat Sizes Page 4. Rehab Seat
BARIATRIC PRODUCTS CATALOG
BARIATRIC PRODUCTS CATALOG Total Solutions for Bariatric Patient Care One Call Does It All 800-537-2521 email: sales@gendroninc.com Total Solutions for Bariatric Patient Care Founded in 1872, Gendron,
Paediatric seating for the Bingo OT. Designed and manufactured by
Designed and manufactured by Paediatric seating for the Bingo OT A breakthrough in rehabilitative stroller seating Introducing the latest innovation from the designers of the revolutionary SPEX seating
Invacare REA Azalea Transit RETAIL Max User Weight 135Kg (21 stone)
Manual Wheelchair Retail Prescription Form ReaAzaleaTransit281117 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com January 2018 Online spares available at: www.invacare.co.uk Customer Ref:
WHEELCHAIR RANGE. aspire for... Comfort Posture Mobility DANISH DESIGN
WHEELCHAIR RANGE aspire for... Comfort Posture Mobility EVOKE REHAB RX ASSIST TRANSIT LITE TRANSIT www.aspirecare.com.au 300 33 0 EVOKE Lightweight & Highly Adjustable The Aspire EVOKE and EVOKE HD are
JZ Imaging & Consulting, Inc Fax:
JZ Imaging & Consulting, Inc. 440-942-1241 Fax: 440-942-1388 BARIATRIC PRODUCTS CATALOG BARIATRIC BEDS & ACCESSORIES Maxi Rest Bariatric Bed... 750-1000 lb...4-5 Extra Care Bariatric Bed...1000 lb...6
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
[ ] Quote [ ] Order. Junior US Retail Price List. Account Information. Ship To Information. Standard Features.
![[ ] Quote [ ] Order. Junior US Retail Price List. Account Information. Ship To Information. Standard Features.](/thumbs/88/114636031.jpg "[ ] Quote [ ] Order. Junior US Retail Price List. Account Information. Ship To Information. Standard Features.")
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
SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5
PARTS CATALOG CONTENTS SIDEFRAME AND CROSSBRACE... ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5 FRONT RIGGING, DETACHABLE... 6 UPHOLSTERY... 7 ACCESSORIES...
Index. By Chair Model. Accessory Cushions & Parts. Seat & Back Pads. Positioning Belts. Trays. Footrests. Cylinders & Cables. Stabilizers/Anti-Tippers
Parts & Accessories Index By Chair Model Accessory Cushions & Parts Seat & Back Pads Positioning Belts Trays Footrests Cylinders & Cables Stabilizers/Anti-Tippers Page Elite 2 MIDLINE 3 30VT 4 Pedal Chair
Transport Chairs / Walkers MRI Transport
MRI Folding Walkers 18 Wide, Depth 17 250 lb weight capacity WA-1000 Adult - 32 to 36 $195.00 ea. WA-1001 Junior - 28 to 32 $195.00 ea. MRI Heavy Duty / Extra Wide Folding Walker 24 Wide, Depth 21 500
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
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: ( )
Standard Base Price: 539
Manual Wheelchair Retail Prescription Form ACTION3JUNIORSMALL19102018 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer
4.6. Clinician/ATP/RTS: City: State: C2MA029 * Required
2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.6 P.O. number:* Date: Ship to:* Helio C2 ORDER FORM - USA Company Name:*
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
Spare Parts Catalogue. Version: 2014/10/08b EN
Spare Parts Catalogue TABLE OF CONTENTS Chassis Sideframes... Crossbrace... 5 6 Seat Seat Upholstery... Solid Seat Inserts..... 7 8 Backrest Legrests Back Cane Assemblies... 9 Back Upholstery... 10 Push
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
Specifications are subject to change without notice. 2018, Amylior Inc. (March 2018) AMYSEAT (Rev.0) Page 1 of 7
Page 1 of 7 ACCOUNT INFORMATION P.O. # or Quote: Dealer Contact Name: Email Address: Phone Number: Bill to (Name): Bill to (Location): Ship to (Name): Address: City: State: User Name or Number: User Weight:
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:
CRT Codes In Separate Benefit Category Legislation (By Code)
# HCCS Description CAT * / ** 1 E0143 Walker, Folding 5-OTH 2 E0637 Combination Sit To Stand, Any Size Including ediatric, With Seatlift 5-OTH Feature, With Or Without Wheels 3 E0638 Standing Frame, One
The maximum standard user weight capacity is 300 lbs (For Invoicing, if Different then "Ship To" Location)
SAVE RESET EMAIL FORM PRINT November, 204 BILL TO: The maximum standard user weight capacity is 300 lbs (For Invoicing, if Different then "Ship To" Location) SHIP TO: Dealer Name: Dealer Name: Contact:
Order no.: ... Date Signature. Posterior seat height
Start M6 Junior Scripted Order no.: Start M6 Junior Lightweight wheelchair Article number: 480F53=60000_K Provide estimate only Order Billing address/customer number Ottobock START_M6_647F263=EN-05-1510
Wallaby Wheelchair. Item #s: WB1200-2GFR, WB1400-2GJB. Accessories WB ELR - Elevating Leg Rests WB Headrest Extension STDS833N - Anti-Tippers
by Wallaby Wheelchair Item #s: WB1200-2GFR, WB1400-2GJB Accessories WB ELR - Elevating Leg Rests WB 8021 - Headrest Extension STDS833N - Anti-Tippers EU Authorized Representative Drive Medical LTD Introduction
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
Shower commode chairs. Ocean. Series
Shower commode chairs Ocean Series Ocean Series Stable, stainless steel frame Individually adjustable seat height: no tools required Machine-washable adjustable backrest with quick-release buckles, can
4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required MVMA053 MVMA056. MVMA058 English Manual (STD) Dutch Manual
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.450 588-6555 1 866 650-6555 F.450 588-0200 orders@motioncomposites.com www.motioncomposites.com 4.8 MOVE ORDER FORM - INTERNATIONAL P.O.
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:
Invacare TARSYS 2G POWER TILT/RECLINE Off Chair SYSTEMS ONLY Suggested Canadian Price List Effective March 1st, 2005 Revised June 18th, 2007
Invacare TARSYS 2G POWER TILT/RECLINE Off Chair SYSTEMS ONLY Suggested Canadian Price List Effective March 1st, 2005 Revised June 18th, 2007 * UPDATED - DENOTES CHANGES NAME PHONE NO ACCOUNT # P.O. DATE
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
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
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)
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: