Serial Number: Manufacturing Date: /20
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1 RGK Head Office: Unit 8 A,B/C Ring Road, Zone 2 Burntwood Business Park, Burntwood Staffordshire. WS7 3JQ. UK Telephone:+44(0) Fax:+44(0) info@rgklife.com Customer Name: Notes/Coents: Address: Postcode: Telephone: VAT EXEMPTION DECLARATION: I declare that I am chronically sick or disabled by reason of: _and that I am receiving from RGK Wheelchairs Ltd, the wheelchair _specified herein and I claim relief from Value Added Tax under group _12 of schedule 8 to Value Added Tax Act Customer Signature: Sales Advisor: Signed: Date: FOR RGK OFFICE USE ONLY Sales Advisor: Total RRP: Customer A/C No: Discount: Serial No: Nett Total: Manufacture Date Wk/Yr: / 20 Deposit paid: OK to Quote: OK to Confirm: Document No: Funding Information & PO No: Who Date ❶ DOC ❷ ❸ Page 1
2 Base Product Mandatory Information Information Required for Option Standard Configuration Option with No Extra Cost Option with Extra Cost ELAXZ010 ELITE A7020 Max User Weight 125kg XW010 CAD drawing for approval KEY FRAME MEASUREMENTS XY010 Seat width (Inside of sideguards) (Max - 500) (Min - 250) XY020 Seat length (Max - 500) (Min - 250) XY030 Seat frame additional length (Provides additional leg support & hand grip) XY050 Front frame height (Max - 630) (Min - 360) XY060 Rear frame height (Max - 630) (Min - 360) XY070 Frame length (Min XY020 + XY ) XA020 Frame ergonomic seat length (Standard = 120) Page 2
3 XY080 Front seat (taper) width Serial Number: FRONT FRAME AND FOOTREST Front Frame Options (Choose One) XA130 Frame V taper seat design (Optional, to provide additional leg support / positioning) Fixed Footrest Footrest Adjustable Footrest ELAXB080 Footrest fixed position integrated into frame ELAXB130 Footrest height and angle adjustable aluminium plate Height and Position Height and Position Footrest height front Footrest height front Rear footrest height Rear footrest height Front of footrest to rear of castor housing Footrest Size (Not ABS) Footrest plate width (Std 200) Footrest plate length (Std 250) Front of footrest to rear of castor housing (If not specified set at 20) Footrest Size (Not ABS) Footrest plate width (Std 200) Footrest plate length (Std 250) Footrest Plate Footrest Plate XB180 Footrest plate aluminium XB100 Footrest ABS moulded foot tray XB190 XB100 Footrest plate carbon fibre Footrest ABS moulded foot tray Specify length (Std 330 if not indicated) ELAXB140 XY330 Specify length (Std 330 if not indicated) Footrest screw and spacer kit (Allows for 25 increase in height) Castor pin width Optimise measurements (Footrest plate width + 50) Castor Pin Width Page 3
4 ELAXY560 CAMBER BAR, WING AND ANTI-TIP Adjustable Centre of Gravity Fixed Centre of Gravity Centre of gravity adjustable sport ( range) ELAXY510 Centre of gravity fixed sport Specify Camber Angle Specify Camber Angle XY390 Camber angle XY390 Camber angle Wing Options (Choose one) Wing Options (Choose one) ELAXA105 Frame basketball wing round with adjustable ends ELAXA110 Frame integrated basketball wing fixed centre of gravity ELAXA140 Frame without offensive wing ELAXA120 Frame basketball wing round with straight sides ELAXA125 Frame basketball wing arrow ELAXA140 Frame without offensive wing Anti-tip options (Choose one) Anti-tip options (Choose one) ELAXJ030 Anti tip single sport removeable ELAXJ040 Anti tip single sport welded ELAXJ050 Anti tip double sport removeable (With joining bar) ELAXJ060 Anti tip double sport welded (With joining bar) Specify castor pin width Specify castor pin width Optimise measurements (Wide as possible - std if not indicated) Optimise measurements (Wide as possible - std if not indicated) Page 4
5 SIDEGUARDS Sideguard Style ELAXE230 Sideguards welded sport XE050 Sideguards screw on carbon fibre XE030 Sideguards screw on aluminium ELAXE250 Sidetubes only welded aluminium Individual Measurements Sideguard Measurements (Choose One) Optimised Measurements XY230 Sideguard length Sideguard height Backrest height fixed Sideguard 25 above tyre (Follow tyre) Sideguard individual above tyre (Follow tyre) XY245 BACKREST Backrest Height (Choose One) Sideguard level with tyre (Follow tyre) Backrest height adjustable lowest position Ergonomics Rearward Positioning (Choose One) XY360 Backrest angle XG100 Backrest ergonomic design Vertical height Individual (Max -10/+10 Deg) Deg Rearward position Ergonomics Lateral positioning (Choose One) XG110 Backrest inward taper design XG120 Backrest outward flare design Page 5
6 CASTOR AND REAR WHEELS Castor Wheels & Forks XC160 Castor wheel 61 court sport XC180 Castor wheel high performance bearing upgrade (Full set) XC200 Castor fork micro sport Rear Wheels Wheel Size XY420 Wheel size 24" XY430 Wheel size 25" XY440 Wheel size 26" Wheel Gap XY460 Rear wheel gap Rear Wheel Options (Choose One) XK030 XK080 Spinergy Colour Options Wheel Sun Equalizer 36/48 spoke sport Wheel Spinergy SLX 24 spoke sport XK100 Black spoke / Silver hub White spoke / Black Hub XK180 Spinergy spoke colour custom (Specify below) Red spoke / Black hub Blue spoke / Black hub Colour inside Yellow spoke / Black hub Pink spoke / Black hub Green spoke / Black hub Orange spoke / black hub XK330 Wheel Spinergy XSLX R10 heavy duty (18 deg camber angle only) Wheel Spinergy XSLX 24 spoke cross spoked sport Colour outside Note: Supply picture for custom designs XK040 Wheel omit / supply without (Specify wheel type / size / tyre) Handrim Position XY470 Handrim set narrow (Standard if no option selected) XY480 Handrim set wide Handrim Options XL010 Handrim aluminium hard anodised 6 tab XL070 (Standard if no option selected) XL040 Handrim titanium 6 tab XL080 Handrim aluminium hard anodised 12 tab (Not with 24") Handrim set super narrow and cut off (XL040 only) XL050 Handrim stainless steel 6 tab XL090 Handrim remove excess mounting tab (Narrow set only) Tyre Options XM070 Tyre Kenda Kaliente sport red only (Standard if not indicated) XM080 Tyre Tufo MS3 sport tubeless XM090 Tyre Tufo WS3 sport tubeless (24" only) Inner Tube Valve Options XY500 Schraeder inner tube valve XY490 Presta inner tube valve (Standard if no option selected) Page 6
7 Frame Serial Number: FRAME FINISH OPTIONS Components XN010 Specify Code Finish frame powder coated XN150 Specify Code Finish components powder coated (Footrest, camber bar & sideguards) (Standard black if not indicated) ELAXN030 Finish frame brushed XN160 Finish components brushed (Footrest, camber bar & sideguards) ELAXN050 Finish frame polished XN170 Finish components polished (Footrest, camber bar & sideguards) XP040 Upholstery seat sling adjustable tension with straps (Standard if not indicated) UPHOLSTERY Seat Upholstery Backrest Upholstery XR040 XR050 Accessory seat plate aluminium with support tubes (Specify length) (Standard XY020-20) Accessory seat plate carbon fibre with support tubes (Specify length) (Standard XY020-20) XP030 Upholstery backrest adjustable tension with straps (Standard if not indicated) Backrest Upholstery Leather Options XP390 Upholstery backrest air lite centre pad XP070 Upholstery upgrade to leather corners on side wings Leather colour black (Standard if not indicated) Leather colour red Leather colour grey Backrest Accessories XP170 Upholstery with individual embroidery (Please provide.jpeg file and positioning) Page 7
8 CUSHION XP080 Upholstery cushion foam with nylon cover Cushion foam soft Cushion foam medium Cushion foam hard (CMS040) (CMS050) (9lb recon) Cushion thickness 50 Cushion thickness 75 Cushion thickness 100 XP340 XP090 Upholstery cushion foam hard plastazote sport (Indicate max height) Upholstery cushion cover upgrade to air lite XP380 Upholstery cushion cover neoprene STRAPPING XS010 XS050 Strapping 100 velcro basic adjustable sport Strapping 100 velcro pro adjustable sport XS020 XS025 XS030 Strapping click basic sport Strapping click Pelvi Loc 2DA Strapping click Pelvi Loc 3DA Specify strap length XS040 Strapping click mounting points (Pair) Indicate mounting position XS040 ACCESSORIES XC330 Castor fork and stem (Front) spare part XP130 Upholstery frame protectors full length sport XC340 Castor fork and stem (Anti-tip) spare part XA150 Plastic tube fitted to offensive wing XR090 Accessory toolkit XS060 Accessory calf strap XS070 Accessory foot strap XP400 Upholstery back bar protector Page 8
9 NOTES Page 9
Serial Number: Manufacturing Date: /20
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
Serial Number: Manufacturing Date: /20
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
RGK Tiga Sub4. July Serial Number: Manufacturing Date:
Manufacturing Date: Sunrise Medical Head O ce: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: +1.800.263.3390 Fax:+1.800.561.5834 E-Mail: cscanada@sunmed.com www.sunrisemedical.ca RGK
Serial Number: Manufacturing Date: /20
49 Bespoke Inc. 51 Caldari Road, Units 6-7B Concord, ON L4K 4G3, Canada Telephone: +1.866.827.4548 Fax:+1.877.731.7745 49@49Bespoke.com www.49bespoke.com Distributor Name: Dealers Name: Contact Name: Client's
Please make your selection with a cross in the box Standard feature Free of Charge
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Transformer. Rev C. Aug 15, 2010 Page 1 of 8
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Sling Position. Push Handle. q Omit Push Handles N/C q Standard Push Handles 53 q Fold Down Push Handles 80 q Bolt-On Push Handles 109
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Condor Script Form Folding Frame Day Wheelchair 90050
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MEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:
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ORDER FORM Ver.9.0 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
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champion Standard Base Price 1,875 Standard Features
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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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Order Date : carbon. Tension adjustable seat, option DDA0611 is not possible with seat width 320mm
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Town: Postal code: Town: Postal code: CLIENT MEASUREMENTS. Seat Width in cm 38 cm 40 cm 42 cm 44 cm 46 cm. 40 cm
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SPARE PARTS MANUAL WHEELCHAIRS Sideguard 2 5 6 7 4 8 9 0 0 95024 Sideguard, heavy duty, right pc. 02 9502 Sideguard, heavy duty, left pc. 0 42002 Sideskirt black, right pc. 04 4200 Sideskirt black, left
Auftrags-Nr.: Order no.: ... Date Signature. MA 110 Standard
Zenit Active Wheelchair Auftrags-Nr.: Order no.: Zenit Active wheelchair Article number: 480F160=1_AA01_C Provide estimate only Order Billing address/customer number Delivery address Ottobock Zenit_647F557=EN-01-1611
IT S NOT IMAGINARY. IT S REALITY. BRINGING YOU LITTLE WAVE.
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Assembly Product name Item no. Version
MANUAL WHEELCHAIRS 1 Sideguard 1 2 6 3 4 7 8 9 1 1 470019 Sideguard left, complete pc. 2 1 470018 Sideguard right, complete pc. 3 1 420013 Sideskirt black, left pc. 4 1 420012 Sideskirt black, right pc.
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
STD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD
P.O. number:* Company Name:* Ordered by:* 2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com Date: Phone:* 4.7 Ship to:*
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
4.2. Ship to: Vendor: Name: Date: Address: Ordered by: City: Province:
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
3 A7WC10 E-Motion adaptor Kit (2 adaptors)
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 ORDER FORM - INTERNATIONAL P.O.
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
Height adjustable footplates, equipped with nylon heel loops. Standard with maintenance free PU front (7 ) and rear wheels (24 ).
Excel G-lite + Compact foldable aluminium wheelchair Perfect for taking with you wherever you go due to its light transport weight and compact size. Comfortable back upholstery. Height adjustable comfortable
Zippie Zone July 2018 EIRZ1
Zippie Zone July 2018 EIRZ1 Date: SUBMITTING F: Quote Order Dealer Acct #: Dealer: PO#: Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: PV: PC: Address: Dealer Phone: ( ) Fax: ( ) Address:
Custom Manual Options & ACCESSORIES AUSTRALIA 2013
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Basic price 2.250,- Excl. VAT
Date Invoice address Invoice address = delivery address Customer code C- Contact person Reference Other delivery address Quote Seat width D64035 35 cm D64040 40 cm D64045 45 cm D64050 50 cm = Standard
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
Quickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,
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YOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP.
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lightweight-rigid for handling and performance
efficient f ff driving i f c itechnology i e cn t i de r ni v 02 driving technology Helium encompasses the latest in cycle and automotive racing technologies for the 2010 decade. Designed and engineered
NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM.
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contents parts description 1/2 FOLD MECHANISM
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Additional Front Wheel Options Not Shown FW1 3 x.75 Micro-Caster FW14 4 x.75 Plastic Wheel w/poly Tire FW3 4 x.75 Light-Up Micro-Caster
front wheels FW2 3 x.75 Light-Up Micro-Caster FW23 3 x1.5 Billet Aluminum Micro Caster w/soft Roll Tire FW19 4 x.75 Performance 5 Spoke Billet Aluminum Wheel w/poly Tire - Silver Hub OR Black Hub FW20
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:
Excel G-Modular Van Os Medical UK Ltd.
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Customer code C- Invoice address. Max. 90 kg See page 5 Side upholstery (reduces SW with 2 x 2 cm) = Standard equipment
Date Customer code C- Invoice address Contact person Reference Other delivery address Quote Invoice address = delivery address Basic price: 3.495,- excl. VAT Seat width D2025 D2030 D2035 25 cm 30 cm 35
Quickie QX December 2018
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Quickie QX July 2017
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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
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Mg-A Order Form Update- 119
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User Manual. TIGA User Manual Issue No: Need replacement parts?
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Küschall K - Junior INVACARE IRELAND LTD Maximum user weight 60kg ( 9.5 Stone )
Invacare Ireland Ltd Manual Wheelchair Unit 5, Seatown Business Campus Ireland Prescription form Seatown Road LPF1U2K-Junior010712IRE Swords, Co Dublin LPF0618U Tel: (00353) 1 8107084 Fax: (00353) 1 8107085
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4.1 MOVE. ORDER FORM - CANADA Ship to: Name: Address: Account: Vendor: Date: Ordered by: Marked for: User manual: PO: Postal Code: Phone:
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