Bio-ST ST & ST-HD. Modifications Removable and/or Additional Foam Shape Contour Covers A A A A & A

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1 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: Inside Contact: Phone: Fax: Mobility Brand: Model: Size: (W) x (D) Interim Fit One Piece System Dimension Letter Description A Seat Width Rt Rt Rt Lf Lf Lf B C D E F G H I J K L Seat Depth, Actual Seat Depth, Before Tail Seat Depth, Overall Back Width Back Height Lateral Trunk Width Lateral Trunk Height Lateral Hip/Thigh Width Lateral Knee Width Lateral Knee Off Seat Medial Knee Off Seat Seat and Back System Products Seat Model # Full Width Mount Between Rails Mount Back Model # Full Width Mount Between Rails Mount Size (Rt, Lf) A: B:, C:, D:, E: F: Modifications Removable and/or Additional Foam Shape Contour Covers A A A A & A A A A A & A Hardware A 4.1. A 4.1. Notes Rev: Page 1 of 6

2 Modifications to the Shape of a Solid Seat Insert or Cushion A # SSI I Modification # SSR 90 Degree Leg # SSL 90 Degree Leg # SSE Angled Cut for Leg # SSD Angled Cut for Leg # SSB Notch for Back Canes # SSC Notch for Cross Braces # SSH Notch for Hangers Rev: Page 2 of 6

3 Modifications to the Contour of a Solid Seat Insert or Cushion A # SCA Anti Thrust Construction # SCB Abductor Contour #SCD Adductor Contour # SCG Abductor and Adductor Contour # SCI Ischial Recess # SCE BioWell: Abductor & Adductor Contour w/ Ischial Recess #SCF Rolled Foam at Front of Seat # SCO Left Pelvic Obliquity Buildup # SCP Right Pelvic Obliquity Buildup # SCR Seat Rail Cutout # SCU Undercut Front of Seat Rev: Page 3 of 6

4 Modifications to the Shape of a Solid Back Insert A # BSI I Modification # BST T Modification # BSC Curved Top of Back # BSS Scapular Cutouts # BSH Bi-Angular Back # BSL Ht, Depth & Angle Adj. Lumbar Support Modifications to the Contour of a Solid Back Insert A # BCM Mild Contour Back, Full Height # BCD Deep Contour Back, Full Height # BCQ Mild Contour Back, 1/3 Ht of Back # BCR Deep Contour Back, 1/3 Ht of Back Rev: Page 4 of 6

5 Modifications to the Contour of a Solid Back Insert (continuation) A # BCC Cutouts for Back Canes # BCL Internal Lumbar Roll # BCS Reduce Foam for Scapular Relief Positioning Support Pads and Hardware B 1. Products Lateral Trunk Supports Model # B Distance Between Dimension in Front of Seat Hardware B 1.2. Notes Lateral Hip/Thigh Supports B Lateral Knee Supports B Medial Knee Support B BioForm Joystick Handles Products Model # Notes BioForm Goal Post Joystick Handles BioForm T Joystick Handles B B Rev: Page 5 of 6

6 FITTING / ORDER FORM Positioning Belts, Straps and Pads Products Model # Notes BioForm Anterior Trunk Supports BioForm Abdominal Binders BioForm Positioning Belts BioForm Positioning Belts with Split Pads BioForm Chest Positioning Belts BioForm Calf Straps BioForm Thigh Straps BioForm Padded Sleeves B 2.1. B 2.2. B 2.3. B 2.4. B 2.5. B 2.6. B 2.7. B 2.8. Products Model # Notes BioForm Foot Positioners BioForm Footplates BioForm Sandals and Straps BioForm Solid Heel Cups BioForm Foot Support Accessories BioForm Foot Boxes BioForm Calf Supports BioForm Anterior Knee Blocks Lower Extremity Supports B 3.1. B 3.2. B 3.3. B 3.4. B 3.5. B 3.6. B 3.7. B 3.8. Head Support Systems Products Flat Headrest Pad Pad Model # B Hardware Model # B 4.3. Modifications B 4.2. Removable and/or Additional Cov- Shape ers Notes BioCurve Headrest Pad B BioForm Cervical Control Headrest Pad BioForm Tri-Pad Headrest, Angle Adjustable Wings BioForm Tri-Pad Headrest, Fixed Wings BioCurve Headrest Package B B B B Rev: Page 6 of 6

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