ACTA-BACK CONTOUR ORDER FORM
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1 ACTA-BACK CONTOUR ORDER FORM PRICING IN CANADIAN DOARS Company Name/ACCT #: Acta-Back Contour 5 Shown with Compass 4 Quick Release 2 Point Hardware. Cover appearance may vary with hardware selection. Acta-Back Contour 8 P.O. Number: Requested By: Phone: Ship To: Patient Reference: Fax: For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then or print and fax to Customer Service at sales.ca@permobil.com or SIZE SEECTION Required ENGTH* ENGTH* Acta-Back Contour 5 BASE MSRP $1, Acta-Back Contour 8 BASE MSRP $1, Sizes available are subject to hardware being used. ACTA-BACK CONTOUR 5 PART NUMBER ABC5-BS 24 *ength () refers to the actual size dimension of the support from bottom to top edge. Sizes available with 2 POINT Hardware ENGTH* ENGTH* Sizes available with 4 POINT Hardware Sizes available with POER Hardware Sizes available are subject to hardware being used. ACTA-BACK CONTOUR 8 PART NUMBER ABC8-BS Please fill in one of the above part numbers with dimensions from the size charts to the right. Example Part: ABC5-BS1816 Hardware will be selected in Section 2. ENGTH* IF DESIRED SIZE IS NOT ISTED, PEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE ACTA-BACK CONTOUR ORDER FORM Patient Reference: PAGE 1 of 5
2 COVER & HARDARE SEECTION 2 Required 2.1 COVER SEECTION MSRP $0.00 Both fabrics are latex-free. Fabric selection is for the support surface only. Other fabrics used in cover construction remain the same. COMFORT-TEK is a smooth, easily cleaned surface. The fluid protection aids in infection control. COMFORT-TEK Cover (COMFORT-TEK) STRETCH-AIR has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant. STRETCH-AIR Cover (STRETCH-AIR) 2.2 HARDARE STYE COMPASS 4 QUICK REEASE COMPASS 4 FIXED COMPASS POER MOUNT Price included in back support purchase Price included in back support purchase MSRP add $78.13 FIXED fully adjustable hardware requires tools for back support removal POER MOUNT hardware has 8 of height adjustment in ½ increments without using tools. QUICK REEASE 2 POINT (Q-COMPASS) QUICK REEASE 4 POINT (Q-COMPASS4) 4 POINT hardware is required on all 24 back supports using Compass 4 hardware. TOP VIE FIXED 2 POINT (NQ-COMPASS) FIXED 4 POINT (NQ-COMPASS4) QUANTUM w/ TRU BAANCE 3 (PMB-QUANTUM) PERMOBI w/ CORPUS 3G (PMB-PERMOBI) QUICKIE w/ 3.7 POER (PMB-QUICKIE) AVID REHAB w/ POER T & R (PMB-AVID) ROVI w/ MOTION CONCEPTS* (PMB-ROVI) *Using Power Mount Hardware on ROVI requires mounting to the RECESSED PANAR INTERFACE PATE available when ordering the Motion Concepts Seating System. Drilling is required for mounting. ACTA-BACK CONTOUR ORDER FORM Patient Reference: PAGE 2 of 5
3 3 BACK SUPPORT ADD-ON SEECTIONS 3.1 COOR 3.2 EMBROIDERY 3.3 MSRP $52.08 PRIVACY FAP MSRP $52.08 MSRP $72.92 Accent colors are applied via colored piping. Placement of the piping may vary by back support size and mounting hardware. If no colors are selected, our standard silver reflective piping is used at no additional cost. A. THREAD COOR OPTIONS RED (EMB-RED) BUE (EMB-BUE) PURPE (EMB-PURPE) GREEN (EMB-GREEN) PINK (EMB-PINK) SIVER (EMB-SIVER) This flap connects with hook & loop attachment between the seat and back for added privacy. Color ocation B. FONT OPTIONS Helvetica (EMB-Helvetica) (EMB-Twilight) Garamond (EMB-Garamond) (EMB-Script) C. ORD ONE Privacy Flap 4 RED (RED) PURPE (PURPE) PINK (PINK) BUE (BUE) GREEN (GREEN) ORANGE (ORANGE) REMOVE (REMOVE) BODIINK HEAD SUPPORT HARDARE & PADS ORD TO (optional) *ADDITIONA EAD TIMES MAY APPY PRIVACY FAP (PV-FAP) You may make one selection per column. Choose between premium (4.1) -or- basic (4.3). Choose 14 a x 5 cover Head material Support Pad in 4.2 Pictured -or PREMIUM PAD SIZE MSRP $ ength () refers to the actual size dimension of the support from bottom to top edge. 4.2 PREMIUM PAD COVER MATERIA 6 x 3 Pad Firmness Extra B-HSP1-63 B-HSP2-63 FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FUID RESISTANT. 8 x 4 Extra B-HSP1-84 B-HSP2-84 COMFORT-TEK FOR FUID PROTECTION & AN EASIY CEANED SURFACE. 10 x 5 Extra B-HSP1-105 B-HSP2-105 STRETCH-AIR FOR AIR TRANSMISSION & HEAT DISSIPATION. 12 x 5 Extra B-HSP1-125 B-HSP x 5 18 x 5 Extra Extra B-HSP1-145 B-HSP2-145 B-HSP1-185 B-HSP2-185 Glideear (GIDEEAR) (add $78.13) Comfort-Tek (COMFORT-TEK) Stretch-Air (STRETCH-AIR) Premium Head Support Pads angles can be formed by adjusting the plates in the pad. ACTA-BACK CONTOUR ORDER FORM Patient Reference: PAGE 3 of 5
4 4.3 BASIC PAD SIZE MSRP $ ength () refers to the actual size dimension of the support from bottom to top edge. 4.4 BASIC PAD COVER MATERIA 6 x 5 B-HSP3-65 COMFORT-TEK FOR FUID PROTECTION & AN EASIY CEANED SURFACE. 8 x 5 B-HSP3-85 STRETCH-AIR FOR AIR TRANSMISSION & HEAT DISSIPATION. 10 x 6 12 x 6 B-HSP3-106 B-HSP3-126 Basic head support pads can be formed to any shape using the moldable steel insert inside the pad. Comfort-Tek (COMFORT-TEK) Stretch-Air (STRETCH-AIR) 14 x 6 B-HSP x 6 B-HSP HEAD SUPPORT HARDARE A. PT HARDARE, REMOVABE PT HARDARE, MID 6 PT HARDARE, AT 6 PT HARDARE, MID 8 PT HARDARE, AT 8 SIZE & SHAPE MSRP PART NUMBER MID 6 $ (B-HS-PT1RMMID6) AT 6 $ (B-HS-PT1RMAT6) MID 8 $ (B-HS-PT1RMMID8) AT 8 $ (B-HS-PT1RMAT8) MAX 8* $ (B-HS-PT1RMMAX8) You may make one selection per column in either A -or- B. If choosing 4.5 A, choose a stem length option next. Choose which mounting block option you require in 4.6. PT HARDARE, MAX 8 *Provides the greatest amount of articulation and range of motion. STANDARD PT STEM, 7 PT STEM, 3 PT HARDARE RANGE OF MOTION PT MODE TOTA # OF INKS TOTA INK ENGTH ANTERIOR POSTERIOR ATERA MID N/A AT MID N/A AT MAX PT HARDARE, STEM ENGTH OPTION STEM ENGTH MSRP PART NUMBER STANDARD 7 STEM $0.00 (HS-STEM-7) **3 STEM $0.00 (HS-STEM-3) **3 Stem is recommended for use with power mounting where there may be special constraints with power chair functions B. 4.6 GT HARDARE, REMOVABE GT HARDARE, ATERA MOUNTING BOCK- POSTERIOR A GT HARDARE, MID-INE HEAD SUPPORT MOUNTING OPTION GT HARDARE RANGE OF MOTION GT MODE TOTA # OF INKS TOTA INK ENGTH ANTERIOR SIZE & SHAPE MSRP PART NUMBER ATERA $ (B-HS-GT3RMAT) MID-INE $ (B-HS-GT3RMMID) POSTERIOR ATERA AT MID N/A MOUNTING BOCK OR BRACKET MSRP PART NUMBER POSTERIOR A MOUNTING BOCK $0.00 (HS-MB-POSTA) ACTA-BACK CONTOUR ORDER FORM Patient Reference: PAGE 4 of 5
5 4.7 EXTRA HARDARE INK ENGTH MSRP EXTRA PART *EXTRA 2 INK $ (B-HS-PT1INK2) *EXTRA 3 INK $ (B-HS-PT1INK3) *EXTRA 4 INK $ (B-HS-PT1INK4) TOO-ESS ING OCK MSRP EXTRA PART EXTRA PART EXTRA PART EXTRA PART *1 OCK $41.67/each (B-HS-52INGA1) (B-HS-52INGA1) (B-HS-52INGA1) (B-HS-52INGA1) ADDITIONA MSRP EXTRA PART 1/4 SPACER PATE $78.13/each (B-HS-SPCRA) *FOR PT HARDARE ONY ACTA-BACK CONTOUR ORDER FORM Patient Reference: PAGE 5 of 5
ACTA-RELIEF LTS ORDER FORM
ACTA-REIEF TS ORDER FORM HCPCS CODING: E2620 POSITIONING BACK, PANAR ITH ATERA SUPPORTS Acta-Relief Patent Pending Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference:
CUSTOM ACTA-BACK DEEP - FULL ORDER FORM HCPCS CODE: E2617
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This back support is also available through. Sizes available with 2 POINT Mounting Hardware
ACTA-BACK ER FM HCPCS COING: E2613/E2614 Company Name/ACCT #: POSITIONING BACK P.O. Number: Requested By: Phone: Fax: Email: This back support is also available through Ship To: Patient Reference: For
2 Required RADIUS BACK ORDER FORM RB-BS. SIZE SELECTION Required COVER & HARDWARE SELECTION COVER SELECTION MSRP $0.00 HARDWARE SELECTION MSRP $0.
RAIUS BACK ER FM HCPCS COING: E2611/E2612 GENERA USE BACK Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference: Fax: For best results, do not fill out in your browser.
CUSTOM ACTA-RELIEF SEAT SUPPORT SURFACE FULL ORDER FORM - HCPCS CODE: E2617
CUSTOM ACTA-REIEF SEAT SUPPT SURFACE FU DER FM - HCPCS CODE: E2617 Patent Pending CUSTOMER/PATIENT INFMATION For best results, do not fill out in your browser. Interactive form should be completed using
CUSTOM ACTA-RELIEF - FULL ORDER FORM Patent Pending
CUSTOM ACTA-REIEF - FU DER FM Patent Pending HCPCS CODE: E2617 CUSTOMER/PATIENT INFMATION For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after
CUSTOM ACTA-BACK - FULL ORDER FORM HCPCS CODE: E2617
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CUSTOM ACTA-EMBRACE BACK - SHORT ORDER FORM HCPCS CODE: E2617
CUSTOM ACTA-EMBRACE BACK - SHORT ORER FORM HCPCS COE: E2617 Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference: Fax: For best results, do not fill out in your browser.
CUSTOM ACTA-EMBRACE BACK - FULL ORDER FORM HCPCS CODE: E2617
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IBERTY X ER FM HCPCS COING: E2622 AJUSTABE SKIN PROTECTION iberty X shown with GlideWear iberty X iner and Foam Base Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient
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ADJUSTER LOW & ADJUSTER DER FM HCPCS CODING: E2622/E2623 - ADJUSTABLE SKIN PROTECTION Adjuster Low Adjuster Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference: Fax:
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CUSTOM INCEPTION CUSHION ORDER FORM HCPC CODE: E2609
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CUSTOM INCEPTION SEAT SUPPORT SURFACE SHORT ORDER FORM
For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then email to customs@comfortcompany.com or print and fax to
CUSTOM INCEPTION SEAT SUPPORT SURFACE SHORT ORDER FORM
For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then email to customs@comfortcompany.com or print and fax to
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I C O N hug ski r aft climb shop Ventu
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