Voyager Evo. Rigid-frame active wheelchair. Standard equipment. Canada: Fax: Order Form and Price List
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1 Voyager Evo Rigid-frame active wheelchair Order Form and Price List Canada: Fax: Provide estimate only Account Information Order Article number: 480A76=00000_K Date Account Number Bill To Phone Number Fax Number Address Buyer P.O. Number Physician/Therapist Ship To Technical modifications and printing errors reserved. Name Address City Address State/Zip Code Phone Number P.O. Number Physician/Therapist Standard equipment Custom-made rigid-frame wheelchair Rigid axle, carbon fiber High-strength carbon frame Crossbrace, carbon fiber Seat height spacers in carbon fiber Carbon footplate Carbon side panels Rear wheels with quick-release axles Knee lever wheel lock Load capacity: kg Ottobock 647F455VOYAGER_EVO=EN Voyager Evo 1/5
2 Wheelchair measurements* 1 Seat width (SW) = distance between the side panels 2 2 Seat depth (SD) = front of seat upholstery to centre of the lower screw on the back bracket 6 3 Anterior seat height (ASH) = ground to top of seat upholstery 1 4 Posterior seat height (PSH) = ground to top of seat upholstery 5 Tipping point = distance between centre of axle and centre of the lower screw of the back bracket 6 Back height (BH) = top of seat tube to top of back upholstery 3 7 α Lower leg length (LL) = top of seat upholstery to top of footplate (without seat cushion) 8 Front frame angle = angle between seat tube and front frame * This information will help to support user-oriented settings and product development. Ottobock guarantees the confidential and purely internal use of this information. Wheelchair settings (in increments of 1 cm) Weight of the user... kg 1 Seat width (SW)... cm 12.5" - 18" (32-46 cm) 2 Seat depth (SD)... cm 14" - 20" (36-52 cm) 3 Anterior seat height (ASH)... cm 17" - 21" (44-53 cm) 4 Posterior seat height (PSH)... cm 15" - 19" (38-48 cm) 5 Tipping point... cm 2" - 4" (5-10 cm) 6 Back height (BH)... cm 8" - 20" (20-50 cm) 7 Lower leg length (LL)... cm 5" " without seat cushion (12-47 cm) Carbon Fiber Package Frame tube 480A76=0000_K MA 12 Carbon (Front frame angle set at 85 with 1 [2 cm] offset) $ Axle MA 13 Carbon Crossbrace MA 17 Carbon Seat height spacer MA 18 Carbon 8 Front frame angle MA Frame Upgrade Option (Decreases product weight) Magnesium Connectors MA 28 $ Frame tapering MA 15 1" (2 cm), taper Frame accessories MA 51 Tip-assist, right $ MA 52 Tip-assist, left $ MA 55 Anti-tipper, right $ MA 56 Anti-tipper, left $ Voyager Evo 2/5
3 Frame options MA 23 Front frame extension 2" (approx. 4 cm) $ Caster wheels MF 01 3" skater caster, hard MF 11 3" luminous caster $65.00 MF 02 4" solid rubber, grey MF 21 4" luminous caster $65.00 MF 35 4" Froglegs soft caster, aluminium $ MF 03 5" solid rubber, grey MF 36 5" Froglegs soft caster, aluminium $ Caster Forks MF 90 Caster fork standard Rear wheel size MG 01 22" MG 02 24" MG 03 25" Axle with camber MG 40 0 MG 41 3 MG 42 6 Rear wheel rim MG 06 Hollow rims MG 10 Spinergy SPOX (cannot be combined with MG 01) $ MG 11 Spinergy LX (cannot be combined with MG 01) $ MG 15 Infinity Ultralight $ Spoke Protectors 481G00=ST G00=ST G00=ST G00=ST G00=ST G00=ST G00=ST G00=ST G00=ST G00=ST766 Spectrum 22 Spectrum 24 Miracle 22 Miracle 24 Network 22 Network 24 Robots 22 Robots 24 Graphic 22 Graphic 24 Tires MG 31 Schwalbe RightRun, 1" MG 33 Schwalbe DownTown 1" (available only in combination with MG 02) $ MG 37 Schwalbe Marathon Plus Evolution 1" $ Voyager Evo 3/5
4 Push rings MG 52 Aluminium, silver anodised, high MG 53 Aluminium, silver anodised, low $75.00 MG 54 Rubber-coated, high $ MG 56 Stainless steel, polished, high $75.00 MG 57 Stainless steel, polished, low $ MG 58 Titanium, polished, high $ MG 62 MaxGrepp Original $ MG 61 The Surge $ MX 27 Natural fit, regular grip $ Push ring mounting MG 70 Narrow mounting position MG 71 Wide mounting position Rear wheel accessories MG 87 High-pressure air pump, 14 bar $ MG 90 Spoke protector, transparent $ Wheel locks MH 01 Knee lever wheel lock, standard MH 05 Scissor wheel lock Outfront $ Back system MD 11 Back, foldable onto the seat surface $ MD 12 Fixed back Back upholstery MD 13 Solid back plate, aluminium, padded $ MD 14 Solid back plate, carbon, padded $ MD 03 Upholstery, adaptable, padded $ Push handles MD 53 Telescoping, short (with MD 03 from BH 26) $ MD 56 Fold-down (with MD 03 from BH 26 cm) $ MD 59 Without Side panels Without ME 01 Standard, aluminium ME 12 Standard, carbon ME 14 Carbon clothing protector side panel, assembled* $ ME 16 Carbon clothing protector side panel, not assembled $ *Remaining centre of gravity adjustment possibilities are limited Side panel accessories (available only in combination with ME 01) ME 13 ABS clothing protector, assembled* $ ME 15 ABS clothing protector, not assembled $ *Remaining centre of gravity adjustment possibilities are limited Voyager Evo 4/5
5 Seat upholstery MC 14 Upholstery, adaptable $ MC 19 Solid seat plate, aluminium, padded MC 27 Solid seat plate, carbon, padded $ Seat cushion MC 01 Standard 1" (3 cm) 2" (5 cm) $ Footrests (Indicate lower leg length measurement on page 2) Single-panel footrest, angle-adjustable, aluminium footplate* $ MB 03 [LL 12"-18" (30 46 cm)] MB 02 Single-panel footrest, angle-adjustable, carbon footplate* [LL 12"-18" (30 46 cm)] MB 12 MB 13 Single-panel footrest, angle- and depth-adjustable, aluminium footplate* [LL 5"-17" (12 43 cm)] Single-panel footrest, angle- and depth-adjustable, carbon footplate* [LL 5"-17" (12 43 cm)] MB 06 Aluminium light, fixed* [LL 12"-18.5" (30 47 cm)] * LL can be selected in dependence of wheel size, seat width and anterior seat height. $ $ Footrest accessories MB 71 Leg fixation (calf strap) $30.00 MB 74 Non-slip surface $90.00 Special accessories MZ 52 Tool kit $85.00 MZ 90 Tire-A-Light, red $33.00 MZ 91 Tire-A-Light, blue $33.00 MZ 93 Wheelchair backpack $62.40 MZ 94 Bag for catheter, small $ MZ 94 Bag for catheter, large $ Voyager Evo 5/5
Auftrags-Nr.: Order no.: ... Date Signature. MA 110 Standard
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More informationOrder 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
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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
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Effective 05/07/2014 Company: Account Number: Date: q Quote q PO Number: RTS: Marked For: q Rogue XP 1825 Rogue Width Grow-able Frame. 275 lb weight capacity. Maximum initial : 16. q Rogue 1495 Rogue Standard
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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 orders@motioncomposites.com www.motioncomposites.com 4.2 Helio C2 ORDER FORM - CANADA
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Sunrise Medical Head Office: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: +1.800.263.3390 Fax:+1.800.561.5834 csrcanada@sunmed.com www.sunrise.ca Distributor Name: Dealers Name: Contact
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160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.6 APEX ORDER FORM - International P.O. number:*
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NONO Date User name Company stamp Rigid frame wheelchair Responsible Wheelchair measures Seat width (LS) 24 27 30 33 36 Seat depth (PS) 27,5 30 32,5 35 37,5 40 Seat depth can be increased by 2,5 or 5 cm.
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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: Vendor: Date: Ordered by: Email: Marked for: User
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160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio A6 ORDER FORM - INTERNATIONAL P.O.
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160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 P.O. number:* Date: Ship to:* Company Name:*
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2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.7 VELOCE ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
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Im Hofstätt 11 D- 72359 Dotternhausen Tel +49 (0)7427 9480-0 Fax +49 (0)7427 9480-7025 e-mail info@proactiv-gmbh.de www.proactiv-gmbh.de Quotation date: Order date: according to GTC PRO ACTIV GmbH Speedy
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4.7 160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com Helio C2 ORDER FORM - INTERNATIONAL P.O.
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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 orders@motioncomposites.com www.motioncomposites.com 4.2 MOVE ORDER FORM - CANADA
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160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.6 P.O. number:* Date: Ship to:* Company Name:*
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160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.7 Helio A6 ORDER FORM - CANADA P.O. number:*
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160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio A6 ORDER FORM - CANADA P.O. number:*
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2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
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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.
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160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio KIDS ORDER FORM - CANADA P.O. number:*
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160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.7 Helio A7 - FiveDay ORDER FORM - CANADA P.O.
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