Order Form XL5 and XL5ci manual wheelchair
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- Jeffry Butler
- 5 years ago
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1 Order Form XL5 and XL5ci manual wheelchair ate : P.O.#: ccount#: Made for (client) : Ordered by : NIN MSRP Organization: ddress : Phone : Fax : ONFIRM ORER Y E-MIL Yes No SUSRIE TO PHYSIPRO NEWSLETTER Yes No YOUR EMIL RESS 01 XL5 Manual Wheelchair (minimal seat-to-floor height of ") $ XL5ci Manual Wheelchair (minimal seat-to-floor height of 11 ½") $ FRME OLORS (Visit our website to view colors) 03 FRME Glossy lack Silver Gloss White Plum andy Red andy Green Purple Green Forest andy lue lack Matte harcoal STNR FOLING MEHNISM 04 Seat Width 12" " " " " " " Weight apacity: Standard Mechanism Model 250 lb 05 Seat epth " " " " " 19" 20" OULE FOLING MEHNISM TIVE USER, SPSTIITY, RITRI (WE SUGGEST THE OULE ROSS-RE FROM " WITH N 250 POUNS N OVER) $ Seat Width 12" " " " " " " 19" 20" 21" 22" 23" 24" Seat epth " " " " " 19" 20" 21" 22" 23" 24" 08 Heavy uty (Necessary with 23" and 24" width), RITRI) $ 280 K POST 09 ack Post Options Straight with push handle 0 8 end with push handle 10 Fold down push handle $ 7 NGLE JUSTLE KREST WITH PUSH HNLE 11 ack ngle YNMI KREST 12 ynamic ackrest $ 575 K HEIGHT SETTING (WITH JUSTLE UPRIGHTS) ack Height " to 20" esired Height : " ack Height Modification from 12" to " and from 21" à 25" esired Height : " NGLE JUSTLE STROLLER R ngle adjustable pushhandles * an not be installed when a Tension ar is requested $ 95 Pair $ 5 Page 1 of 6
2 SET UPHOLSTERY N K SET $ 325 Urethane ushion 2" $ 0 19 Urethane ushion 3" $ 0 20 Ultra ushion 21 Zero-Pressure ushion 22 LX ushion 23 Omit 24 Standard Upholstery 25 Omit ackrest 26 XIS tension adjustable back 27 VLEO backrest 28 HP2 backrest 29 Tension ar $ 5 30 Tension ar with Multiadjustable headrest support mounting fixture $ Symbio $ 3 32 Multi-djustable offset $ Multi-djustable straight $ 7 Standard Seat Sling Rigid (flat) rop Seat 1" 1 ½" 2" NIN MSRP Page 2 of 6 K HEREST SUPPORT P Small (7 x4 ) Medium (8 x5 ) Large (9 x6 ) $ 220 Small (6 x 4½ ) Medium (7 x5 ) Large (8 x 6 ) $ 252 ½" gap on each side ½" gap on each side ½" gap on each side ½" gap on each side ½" gap on each side ½" gap on each side 34 Simple 35 ombination Head/Neck Support Pad RMREST U-TYPE flip back, removable, height adjustable XL5 MOEL 36 From 7" to 12" djustable in ½" increments 37 rmrest Height Modification Less than 7" or over 12" XL5I MOEL " U " Model 38 From 8" to " djustable in ½" increments 39 rmrest Height Modification Less than 8" or over " L-TYPE XL5 MOEL 40 From 8" to 10" djustable in ½" increments 41 rmrest Height Modification Less than 8" More than 10" XL5I MOEL 42 From 9" to 11" djustable in ½" increments 43 rmrest Height Modification Less than 9" More than 11" " L " Model T-TYPE, REMOVLE, HEIGHT JUSTLE XL5 MOEL 44 From 8" to " djustable in ½" increments XL5I MOEL 45 From 9 ½" to ½" djustable in ½" increments " T " Type Physipro inc. 370, 10th South ave., Sherbrooke (Quebec) J1G 2R7
3 RMP FOOTREST N RTIULTING LEGREST FOOTREST - SWING WY N JUSTLE IN HEIGHT FROM " TO 19" $ 9 Pair 53 Footrest Height Modification Less than " or over 19" Please enter you desired height " (±1/4") ELEVTING N RTIULTING LEGREST including calf support and standard footplate $ 79 Pair 54 Pair $ Singular Legrest Right Left $ " to " " to 19" esired Length : " esired Length: " 46 esk Length Full Length 47 rmrest rmpads, Waterfall Style w/gel size 3'' x '' $ 200 Pair 48 Tubular rmpad (vailable with L-Type rmrest only) $ Pair 49 3" rmpad Extension Right Left $ 124 Pair NIN MSRP Page 3 of 6 LF SUPPORT (6" X 8") 57 Standard Padded Included when ordering elevating legrest $ 5 ea. 58 Standard Padded With Gel $ 225 ea. 59 Profiled Padded Standard Included when ordering elevating legrest $ 5 ea. 60 Profiled Padded With Gel $ 235 ea. FOLING FOOTPLTE omposite flip up footplate, standard size Width 6" epth 6 ¾" ngle and depth adjustable, standard size Width 6" epth 6 ¾" $ 0 Pair 63 ngle and depth djustment, oversized Width : 6" or 7" or 8" epth : 9" or 10" $ 195 Pair 64 One piece footplate angle, depth adjustable 6" up to 10" epth esired depth " $ 350 Pair 65 Front anti-tippers $ 84 Pair STRP 66 Heel Support Strap djustable in Length 67 alfrest Support Strap $ 120 WHEEL LOK 68 Push to lock 69 Pull to lock $ 4 Pair 70 Fixed Extension Handle $ 40 Pair 71 Telescopic Extension Handle $ 60 Pair Extension Handle
4 ESSORIES STERS 72 Positioning elt uto uckle, 2" $ Positioning elt Velcro 74 nti-tip 75 Four distinct tie-down securement locations $ Polyurethane 8" x 1 ¼" 77 Polyurethane 5" x 1 ½" 6" x 1 ½" 8" x 1 ½" 78 Polyurethane 4" x 1" 5" x 1" 6" x 1" 7" x 1" $ 100 Pair 79 Pneumatic 6" x 1 ¼" 8" x 1 ¼" $ 125 Pair RER WHEEL SIZE 80 20" 22" 24" 26" RER WHEEL 81 Mag Wheel 82 Spoke Wheel 83 Heavy uty Spoke Wheel $ 5 Pair RER WHEEL TIRE 84 Polyurethane Standard Pressure Minimum seat-to-floor height is 12" when choosing 20" rear wheel High Pressure Minimum seat-to-floor height is 12" when choosing 20" rear wheel HNRIM OPTIONS $ 80 Pair 87 luminum Handrim 88 Plastic oated Handrim $ 0 Pair 89 Natural Fit Standard grip (oval aluminum handrim with thumb piece) vailable with spoke wheel only $ 320 Pair 90 1/2" loser 91 Omit XLE 92 Threaded 93 Quick Release xle 94 Extension plates for amputee (integrated to the adjusting plate, position 1, p.6) OTHER OPTIONS 95 Oxygen Tank Holder $ 0 96 ane Holder Single $ ane Holder ouble $ PR-000 Transparent Spoke guards $ 0 Pair 99 Physipro Spoke-Guards (special design) Please visit: esired model #: $ 346 Pair NIN MSRP uto uckle Velcro Polyurethane Pneumatic Page 4 of 6
5 FRONT SET TO FLOOR HEIGHT NIN MSRP Page 5 of 6 SELET ESIRE HEIGHT XL5 XL5 I Hemi frame short fork Hemi frame short fork.5.5 ½ ½ ½ 11 ½ ½ ½ ½.5 ½ ½ ½ Standard frame short fork Standard frame short fork ½.5 ½.5 ½ ½.5 ½.5 ½ ½ 19 ½ ½ 19 ½ ½ ½ ½ ½ Standard frame long fork Standard frame long fork ½ ½ ½ ½ ½ ½ ½ 20 ½ ½ ½ ½ ½ ½ ½ ½ ½ ½ 21 ½ ½ ½
6 NIN MSRP Page 6 of 6 RER FLOOR TO SET HEIGHT TLE RER WHEEL IMETER XL5 POSITION 20" ½ ½ E F ½ G H ½ I J ½ 22" ½ ½ ½ ½ ½ 24" ½ ½ ½ ½ ½ RER WHEEL IMETER XL5ci select desired height select desired height 26" ½ ½ ½ ½ ½ POSITION 20 " 11 ½ ½ ½ E F ½ G H ½ I J 22 " 12 ½ ½ ½ ½ ½ 24 " ½ ½ ½ ½ ½ 26 " ½ ½ ½ ½ ½ 19 E F G H I J. REFERENE SHEME : FLOOR TO SET HEIGHT : : RER FLOOR TO SET HEIGHT: RER WHEEL POSITION hoose the rear wheel desired position Front of the wheelchair The positions that are less than 5 become incompatible with a 24 " rear wheels and a depth of ". NOTES Physipro inc. 370, 10th South ave., Sherbrooke (Quebec) J1G 2R7
Order Form XL5 and XL5ci manual wheelchair
Order Form XL5 and XL5ci manual wheelchair ate : P.O.#: ccount#: Made for (client) : Ordered by : 2018-08-03 Organization: ddress : FRME OLORS (Visit our website to view colors) Phone : Fax : ONFIRM ORER
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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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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.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 MOVE ORDER FORM - CANADA P.O. number:* Date:
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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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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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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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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 APEX 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.+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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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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