Quickie QX December 2018
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- Alicia Rich
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1 Quickie QX December 2018 EIF6 Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: PV: PC: Address: Dealer Phone: ( ) Fax: ( ) Address: Confirmation Ship To City: PV: PC: Confirm Via: Fax Ship To Phone: ( ) Fax: ( ) Option # Definition Price Option # Definition Price 1. FRAME Base Model 196WM94 Quickie QX (Fixed Axle) 265 lbs. $1, Base Model 196TO38 Transit System WC19 Frame Style See Seat Height Matrix on page 2 196FS9 196FS30 Standard Frame Hemi Frame 2. SIZE / SEATING Frame Width Seat Depth 196W5 14" Frame Depths equals Seat Depths. 196W6 196SD7 14" 196W7 16" 196SD8 196W8 196SD9 16" 196W9 18" 196SD10 196W10 $ SD11 18" 196W11 20" $ SD71 196SD13 20" $ $ Frame Width - Built 4 Me Options Weight Capacity 300 lbs. Not available with EXO standard or Tension adjustable JAY Cushions (Optional) upholstery, Not available with Ballistic Nylon or 3DX Tension adjustable upholstery. To order any JAY cushions on-chair, please see the JAY price list. 196W59 B4ME - 21" Width $ Cushion name or part number must be filled out with desired width and depth 196W60 B4ME - 22" Width $ JAY Bundled Cushion 196JC20 Cushion Name or Part # Price List Seat Sling Width: Depth: 196SL1 196SL6 Standard Seat Sling Omit Seat Sling ($21.00) Custom Seating 196QC01 196QC02 196QC03 Surefit Configurefit JayFit Quickie QX, Ultra Lightweight Folding Wheelchair Quickie QX featuring the Jay X2 cushion Page 1 of 5
2 3. CASTERS / SEAT HEIGHT Front Seat Height See Front Seat Height Matrix & 13.0 only available w/ 60 hanger 12.5" & 13" only available w/ Alum Angle Adj Footplate 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196CS1 196CS5 196CS9 Caster Stem Bolt Standard 3/4" 1 1/2" Front Seat Height Matrix 196CW3 196CW44 196CW5 196CW7 196CW34 196CW35 196CW32 196CW39 Caster Wheels 4" Low Profile Polyurethane 4" x 1.25" Semi Pneumatic 5" Low Profile Polyurethane 5" x 1.5" Semi Pneumatic 6" Polyurethane 6" x 1.5" Semi Pneumatic 8" Polyurethane 8" x 1.5" Semi Pneumatic $ Caster Fork 196CF71 3.5" (standard stem bolt only) 196CF " 196CF17 6" 196CF23 7" 4. REAR WHEELS / REAR SEAT HEIGHTS Rear Seat Height Rear Wheel Tire See Rear Seat Height Matrix. 12.5" & 18.5" RSH not available with fixed axle. See Rear Tire & Wheel Matrix for availability 196RH9 196RH12 12" 13.5" 196RH11 196RH13 13" 14" 196RT1 196RT2 Pneumatic Pneumatic w/ Airless Insert $ RH " 196RT3 Full Poly 196RH15 196RH " 196RT39 High-Pressure Clincher Black $ RH17 196RH18 196RH19 16" 16.5" Handrim Natural Fit only available w/ 22, 24, 25 Lite Spoke. Plastic N/A w/ 25, 26" 196RH " 196HR1 Aluminum Anodized 196RH20 18" 196HR4 Plastic $ RH21 196HR22 196HR23 Natural Fit - Standard Grip Natural Fit - Super Grip $ $ Rear Wheel Size See Rear Tire & Wheel Matrix for availability 196RW3 196RW8 196RW1 196RW RW RW RW90 196RW91 196RW92 196RW94 196RW25 20" Mag Wheel 22" Mag Wheel 24" Mag Wheel 20" Mag Wheel 5 Spoke 22" Mag Wheel 5 Spoke 24" Mag Wheel 5 Spoke 20" Lite Spoke Wheel 22" Lite Spoke Wheel 24" Lite Spoke Wheel 26" Lite Spoke Wheel Omit $ $ $ ($44.00) Seat Squeeze Matrix Frame Depth Max Seat Squeeze 14" 2.0" - 16" 2.5" - 18" 2.5" - 20" 3.0" Rear Seat Height Matrix Page 2 of 5
3 4. REAR WHEELS / REAR SEAT HEIGHTS (CONT) Rear Tire & Wheel Matrix One Arm Drive Available only with 24" MBL Lite spoke wheels. Std Aluminum black handrim 196AL16 One Arm Drive Adj. Axle Plate $1, HM1 Right Hand Mount 196HM2 Left Hand Mount Axle 196AX1 Quick Release Steel 196AX11 Quad Quick Release Steel N/A on Spoke $ AX45 Threaded Axle $ WHEEL LOCKS 196WL1 196WL2 196WL30 196WL24 196WL23 196WL10 196WL12 Wheel Lock High Mount Push High Mount Pull Compact $ Unilateral Wheel Lock Right $ Unilateral Wheel Lock Left $ Omit Wheel Lock Do Not Mount Extension Handle Ext. handles only available with high mount push or pull wheel locks 196EH7 Extension Handle (Pair) $ HANGERS AND FOOTRESTS Front Hangers Footplate mounts with Extension Tube using clamping hardware 196H Swing In/Out Hanger 196H Swing In/Out Hanger 196H Swing In/Out Hanger Articulating Hanger 196H159 N/A w/ Alum Angle Adj Front Mount footplates. Elevating Hanger - Ext Mount 196H160 N/A w/ Alum Angle Adj Front Mount footplates. Elevating Hanger - Front Mount 196H161 Only available w/ front mount alum angle adj footplates and 14"-22" width 196H144 Omit Hanger & Footplate $ Extension Tubes See Lower Leg Length Matrix for range 196E1 Short 196E2 Medium 196E5 Long Footplate Heel loop not included, see Footplate Option section below 196F1 Composite Footplate 196F F3 196F5 196HL A02 Composite Angle Adj (16"-22"w) Aluminum Angle Adj. Footplate Aluminum Only available w/elevating Legrest Hanger & Footplate Options Adjustable Heel Loop Gel Cover For Hangers (Pair) $ $ $ BACKREST / SEATING 196BT10 196BT100 Back Type Standard Angle Adjustable Back Backrest Height 196B5 Med (13"-) 196B9 Tall (16"-20") $ Push Handles Integral Push Handles, Folding Height Adjustable & Omit 8 for Std Backrest, Straight for Angle Adj. Backrest 196PH6 Integral Push Handles Fold-Down Push Handles Only available with Adjustable Upholstery. 196PH5 Used in combination w/angle Adjust only $ avail in 16"-20" back height 196PH17 Folding Push Handle with Ht. Adj. Back $ PH2 Omit Push Handles Page 3 of 5
4 7. BACKREST / SEATING (CONT) Back Upholstery 196BU1 Standard Upholstery 196BU88 Standard Upholstery EXO $ BU70 Backrest Tension Adj Ballistic Nylon $ BU71 Backrest Tension Adj 3DX Vented $ BU89 Backrest Tension Adj EXO $ BU14 Omit Back Upholstery ($21.00) JAY Backs 196JB01 JAY Back (see Order forms) Price List Military Service Patches 196VU1 US Marines Patch 196VU2 US Army Patch 196VU3 US Navy Patch 196VU4 US Air Force Patch 196VU12 US Coast Guard 196VU5 Purple Heart 196VU8 Purple Heart with Marines Patch 196VU9 Purple Heart with Army Patch 196VU10 Purple Heart with Navy Patch 196VU11 Purple Heart with Air Force Patch 196VU13 Purple Heart with Coast Guard 8. ARMREST / SIDEGUARDS Armrest - Padded Swing Away Armpad - For Height Adjustable Some limitations when used with the Angle Adjustable Back in the rear most setting 196AM23 Desk Length (10") Please circle a setting, will default to 11" if no selection is made 196AM24 Full Length - Full (14") 196AA18 Padded Swing-Away STD (9" to 13") $ Setting 9" 10" 11" 12" 13" Armrest Options Armrest - Height Adjustable 1968A01 Gel Cover For Swing Away Arms (pair) $ Flip Back HA Classic N/A w / 14"- depth 196AA AA105 Single Post Ht. Adj - Std (9.75"-14.75") Single Post Ht Adj - Low (8.25"-12.25") 196SG33 Side Guards Plastic - Standard (8.5" High) $ AA65 Flip Back Ht Adj LITE (10"-) $ SG29 Plastic - Low (6.5" High) $ AA AA AA14 Dual Post Flip Back Ht Adj Flip Back Ht Adj Classic (11"-) Omit Armrest $ KEY OPTIONS 196AT1 196A1 1961A01 Anti Tips Anti Tips (Pair) $ Pack Accessories Backpack - Black/Charcoal Adult $ Seat Pouch Black $77.00 Positioning Belt 196A " Auto Buckle w/ Clamps $ A804 Positioning Belt Slide Clamps $71.00 Spoke Guards 1964A01 Quickie Black Spoke Guard $ A02 Quickie Clear Spoke Guard $ Miscellaneous 1968A03 Caddy $ A2100 Crutch Holder $ COLOR Standard Frame Colors Matte Frame Colors 196C140 Aztec Gold 196C116 Matte Black 196C2 Black (Not avail as base w/zebra) 196C151 Matte Black Cherry 196C141 Black Cherry 196C150 Matte Electric Blue 196C10 Black Opal 196C149 Matte Evergreen 196C38 Blue Opal 196C152 Matte Purple 196C36 Candy Blue 196C14 Candy Purple Custom Frame Color 196C35 Candy Red 196C112 Desert Camouflage $ C142 Electric Blue 196C43 Mossy Oak Camouflage $ C143 Evergreen 196C42 Stars & Stripes $ C126 Glow Zebra (Choose above base color) Std 196C144 Green Apple with White unless above base paint is 196C C147 Hot Sparkle Pink chosen N/A w/ Blk, Matte Black, Blk Opal, $ Titanium) 196C148 Mauve Pink 196C103 Rootbeer 196C114 Sparkle Silver Additional Options Through Built for Me 196C145 Sunrise Orange To inquire about any unique customization for Quickie products, contact: Phone: 196C113 Titanium Color Paint (800) , Fax: (800) C8 Yellow Page 4 of 5
5 APPENDIX Front Seat Height Matrix Cont. Lower Leg Length Range Matrix Page 5 of 5
Quickie QX July 2017
Quickie QX July 2017 EIF6 Mark For: Submitting for: Date: PO#: Quote Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: Dealer
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Quickie IRIS FSS Net Order Form/Price List (SIN F-1)
Mark For: Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: Dealer Phone: ( ) Fax: ( ) Confirmation Email: Confirm Via: ZIP: Quickie IRIS FSS Net Order Form/Price List (SIN
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October 2018 EIQ2X. Mark For: Submitting for: Quote Order. ADDITIONAL SHIPPING INFORMATION Dealer Contact: Price. Option # 1. FRAME 002RS1 002RS2
Quickie 2 October 2018 EIQ2X Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: PV:
Quickie QX February 2019
a Mark Fr: Dealer Acct #: Dealer Cntact: Dealer Address: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: Optin # Date: Dealer: Dealer City: ZIP: Quickie QX February 2019 EIF6 Fax Email Ship
Quickie 2 AADL - W137
Quickie 2 AADL - W137 EIQ2X, October 2018 Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer
Quickie QXi July 2018
Quickie QXi July 2018 EIF6 Mark Fr: Submitting fr: Qute Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: PV: PC: Address:
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
Quickie 2 EIQ2N Effective April 2011
Quickie 2 EIQ2N Effective April 2011 ACCOUNT #: SHIP TO: DATE: NAME: P.O. #: ADDRESS: BUYER: CITY/ STATE: MARKED FOR: ZIP CODE: PHONE NUMBER: The HCPCS codes provided are based on code verification by
Quickie GTX Swing-Away FSS NET ORDER FORM/PRICE LIST (SIN F-1)
Account No: Drop Ship/Ship To: Date: Name: P.O. #: Address: Buyer: City: State: Marked For: Zip Code: Phone Number: Seat Depth (Continued) 163SD10 17" NC 163SD11 18" NC 163SD12 19" 1 NC Frame Style 163SD13
Quickie QXi January 2018
a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: Optin # ZIP: EIF6 Fax Email Ship T Phne: ( ) Fax: ( ) Definitin
Quickie QXi January 2019
Quickie QXi SUBMIT January 2019 EIF6 Mark Fr: Submitting fr: Date: PO#: Qute Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: Dealer
Quickie GTX Fixed Frame EIF3, Effective July 2009
Quickie GTX Fixed Frame EIF3, Effective July 2009 Account No: Date: P.O. #: Buyer: Marked For: Drop Ship/Ship To: Name: Address: City: State: Zip Code: Phone Number: The HCPCS codes provided are based
Quickie Qxi November 2016
Quickie Qxi Nvember 2016 EIF6 Mark Fr: Submitting fr: Date: PO#: Qute Order Dealer Acct #: ADDITIONAL SHIPPING INFORMATION Dealer: Dealer Cntact: Ship T: MEDmbility Reference Only Dealer Address: Attentin:
ZIPPIE IRIS (Transit Included) EIZ5A
ZIPPIE IRIS (Transit Included) EIZ5A MASS QLD ORDER FORM SUMMARY PAGE Effective: January, 2014 ORDERING INFORMATION: (02) 9678 6600 Fax: (02) 9678 6655 Email:orders@sunrisemedical.com.au Date: Sales Rep:
Quickie IRIS March 2015
Quickie IRIS March 2015 EIZ4-2 Mark For: Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: Dealer Phone: ( ) Fax: ( ) Confirmation Email: PC Please address all correspondence
QUICKIE P222 SE BD/SD Solid Seat (No Power or Single Power Seating Options) EIPW2 - Effective January 2018
QUICKIE P222 SE BD/SD Solid Seat (No Power or Single Power Seating Options) EIPW2 - Effective January 2018 Account: Date: PO#: Buyer: Marked For: Ship To: Name: Address: City,State,Zip: Phone: The HCPCS
Quickie LXI/LX. January 2019 EILXI/EILX. Address: Ship To City: o Fax o
a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie LXI/LX January 2019 EILXI/EILX Submitting fr:
Kids Quickie 2 SE January 2018 EIZ10
a Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: ZIP: SUBMITTING FOR: Qute Order Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS Definitin Price a Optin # HCPCS Definitin Price KIDS QUICKIE 2
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) Freedom 2 Kids
Freedom 2Kids Manual Wheelchair Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Frame Options FD2K Folding Transport Optional (E1236) or (K0005) FD2K-30270 $2085 Note: Transportation
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Canada AADL CAT # 151 Effective 10/01/2018 Company: Account Number: Date: q Quote q PO Number:
Zippie 2 January 2018 EIZ2
Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: Mark Fr: ZIP: Zippie 2 January 208 EIZ2 SUBMITTING FOR: Qute Order Fax Email Ship T Phne:
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.
Funder: Order Number: Date: q Quote q PO Number: Therapist: Marked For: Catalyst 5 K5-CAT5-ALI 136kg weight capacity Frame Seat Width / Seat Depth Select box corresponding to desired Seat Width and Depth
Account Number: Provider Name: Contact:
Quantum Rehab Discount: Terms: Freight: Taken By: DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. HCPCS codes should not be considered
Custom Manual Options & ACCESSORIES AUSTRALIA 2013
Custom Manual Options & ACCESSORIES AUSTRALIA 2013 Casters and Forks CASTERS FORKS Aluminium Soft Roll 4 X 1.5 113395 5 X 1.5 113396 6 X 1.5 113397 Aluminium Polyurethane / Soft Roll Multi Position Fork
Quickie 2HP July 2018
Quickie 2HP July 2018 EIHP Mark Fr: Submitting fr: Qute Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: PV: PC: Address:
Account Number: Provider Name: Contact:
Discount: Terms: Freight: Taken By: Quantum Rehab A Division of Pride Mobility Products Corporation 82 Susquehanna Ave., Exeter, PA 8643 Phone: (866)800-2002 Fax: (866) 707-3422 DME providers are responsible
Kids Quickie 2 SE November 2012
a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Ship T: Attentin: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirmatin Email: Cnfirm Via: PO#: ZIP: Kids Quickie
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
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
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
Quickie QRi January 2019
a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie QRi January 2019 EIR
q Little Wave Flip XP-Rigid Base E1233, E1161 $
Funder: Therapist: Date: q MOH q ACC Marked For: Details: Ship To: Address: City: Postcode: Phone: Email: Notes: q Little Wave Flip XP-Rigid Base E1233, E1161 $ 74 kg weight capacity. Price includes one
Kids Quickie 2 SE (Without Seating) NOVEMBER 2012
a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirmatin Email: Cnfirm Via: Ship T: Attentin: Kids Quickie 2 SE
Kids Quickie 2 SE (Without Seating) NOVEMBER 2012
a Mark Fr: Submitting fr: Qute Order ST: Dealer Phne: ( ) Address: Fax: ( ) ZIP: Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price KIDS QUICKIE 2 SE W/O
MASS Script Form. Frame. Backrest. Seat Depth. Tsunami ALX K0005 Charge. Sling Position. Seat Width / Seat Depth. Seat Width.
MASS Script Form Company: Account Number: Date: Quote PO Number: RTS: Marked For: Australian Order Form Effective 05/07/2014 Ship To: Address: City: State: Zip: Phone: Email/Fax: Tsunami ALX K0005 Charge
4.6. Clinician/ATP/RTS: City: State: C2MA029 * Required
2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.6 P.O. number:* Date: Ship to:* Helio C2 ORDER FORM - USA Company Name:*
q Little Wave Flip XP - Rigid Base KF-XPRIGID $
Phone 0800 5 222 Fax 0800 275 65 Effective /06/207 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Little Wave Flip XP - Rigid Base KF-XPRIGID $ 9.8kg weight capacity. One time free
Frame Width. Seating Setup. q 16 q 15 q 14 q 17 q 16 q 15 q 14 Short q 18 q 17 q 16 q 15 q 14 q 19 q 18 q 17 q 16 q 15 q 14
Phone 0800 5 Fax 0800 5 365 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Focus CR $ 36kg weight capacity. Tilt range: -5º anterior to 50º posterior. Effective /0/0 Ship To: Address:
QUICKIE S646 SE BD/SD/MPD No Power, Single Power & Multi Power Seating Option AADL - W579
QUICKIE S646 SE BD/SD/MPD No Power, Single Power & Multi Power Seating Option AADL W579 EIS62, October 2018 Account: Date: PO#: Buyer: Marked For: Ship To: Name: Address: City,Province,Postal Code: Phone:
MEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:
Canada MEDmobility 5711- Calgary Trail NW Edmonton AB T6H 2K1 P: 780-437-3300 F: 780-430-9381 www.medmobility.ca Company: Account Number: Date: Quote PO Number: RTS: AADL #W154 Effective 10/01/2017 Ship
Frame. Backrest. Seat Depth. Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time free growth kit. 165 lb weight capacity.
Canada Patent Pending AADL #W157 Effective 10/01/2017 Company: Ship To: Account Number: Date: Quote PO Number: RTS: Marked For: Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time
MASS Script Form. Frame. Backrest. Seat Depth
MASS Script Form Company: Account Number: Date: Quote PO Number: RTS: Marked For: Australian Order Order Effective 01/10/2014 Ship To: Address: City: State: Zip: Phone: Email/Fax: Rogue XP K0005, E1235
Quickie 2HP January 2018
a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie 2HP January 2018 EIHP Qute Fax Email Ship T
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:
C O L O U R S C H U M P - G ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
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:*
4.2 HELIO KIDS MODEL. Ultralight Folding Carbon Fiber HELIO KIDS Wheelchair Including angle & depth adjustable back (79 kg lbs weight capacity)
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
Quickie 2HP January 2017
a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie 2HP January 2017 EIHP Qute Fax Email Ship T
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) PRO-CG. Adult Manual Wheelchair
PRO-CG Adult Manual Wheelchair email: customerservice@freedomdesigns.com TM SE Clear Form Email Form to Customer Service Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Notice: A seating
NXT Pediatric. Manual Wheelchair. Transport Optional Base
Pediatric Manual Wheelchair Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Transport Optional Base Folding (E1234) NXT-30300 $2800 Transport Optional Note: Transportation Option selected
4.6. Clinician/ATP/RTS: City: State: VEMA039 * Required. Veloce - FRONT Seat-to-floor height. 16 to 19 Specify desired height: 80.
2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.6 VELOCE ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
PAGE 2 BREEZY ELEGANCE
PAGE 2 Category... 1 Product... 1... 5 BASE FRAME... 5 AXLE PARTS... 5 CASTER FORK... 6 ANTI-TIP... 7 WHEEL LOCK... 8 DRUM BRAKE... 9 REAR WHEEL - STANDARD... 10 REAR WHEEL - DRUM BRAKE EQUIPPED... 11
BC MEDEQUIP HOME HEALTH CARE LTD SPRINGER AVE, BURNABY, BC
Basic Wheelchair Bid Work Sheet HMEDA Member Name/Address: BC MEDEQUIP HOME HEALTH CARE LTD. 2230 Springer Avenue, Burnaby, BC, V5B 3M7 Contact Person: ANDRE MONTAGANO Phone/e-mail: 604-888-8811 andre@bcmedequip.com
Zippie GS SE January 2019 EIZGS
Zippie GS SE January 209 EIZGS Date: SUBMITTING FOR: Qute Order Dealer Acct #: Dealer: PO#: Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: ST: ZIP: Address: Dealer Phne: ( ) Fax: ( ) Address:
APEX 4.7. FRONT Seat-to-floor height ORDER FORM - USA. Height available +- 1/4" Caster sizes. 3" Caster 14" to 21" Specify desired height:
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:*
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG. Adult Manual Wheelchair
P.R.O. CG Adult Manual Wheelchair TM SE 2241 N Madera Rd Simi Valley, CA 93065 Phone: (800) 331-8551 Fax: (888) 582-1509 www.freedomdesigns.com email: customerservice@freedomdesigns.com Date: Buyer: Company:
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
Zippie TS January 2019 EIZ1A
a ST: Dealer Phne: ( ) Fax: ( ) 187WM63 Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: Cnfirm Via: Mark Fr: 187WM65 187WM64 187WM66 ZIP: SUBMITTING FOR: Qute Order Fax Email Ship
Zippie TS SE January 2019 EIZ1A
a ST: Dealer Phne: ( ) Fax: ( ) ZIP: SUBMITTING FOR: Qute Order Fax Email Ship T Phne: ( ) Fax: ( ) Flding Grwing Zippie TS SE Withut Seating 187WM67 E1234 Transit Optinal $2,575 True Fit Nt Included Date:
Zippie TS SE January 2018 EIZ1A
a ST: Dealer Phne: ( ) Fax: ( ) ZIP: SUBMITTING FOR: Qute Order Fax Email Ship T Phne: ( ) Fax: ( ) Flding Grwing Zippie TS SE Withut Seating 187WM67 E1234 Transit Optinal $2,575 True Fit Nt Included Date:
BENTLEY. Order Form - AADL - W322 Prices in Canadian Dollars. October 1, W h e e l L o c k s. A n t i - T i p p e r s. B a c k P o s t S t y l e
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Tag Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a m e T y
Zippie GS January 2019 EIZGS
Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: Mark Fr: ZIP: Zippie GS January 09 EIZGS SUBMITTING FOR: Qute Order Fax Email Ship T Phne:
Invacare Action 3 Junior Basic RETAIL Max User Weight 80Kg (12.5 stone)
Manual Wheelchair Retail Prescription Form ACTION3JUNIORBASIC05122018 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer
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:
C O L O U R S RAZOR BLADE ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
VELOCE 4.7. FRONT Seat-to-floor height ORDER FORM - USA. Caster sizes Height available +- 1/4" 3" Caster 14" to 21" Specify desired height:
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:*
4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required MVMA053 MVMA056. MVMA058 English Manual (STD) Dutch Manual
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.
RETAIL Max user weight: 100kg - seat widths 12" & 13" Max user weight: 130kg -seat widths 14" -16"
Manual Wheelchair Retail Prescription Form ACTION515112017 Tel: 01656 776222 Fax: 01656 776220 JAN 2018 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer Ref: Contact
SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5
PARTS CATALOG CONTENTS SIDEFRAME AND CROSSBRACE... ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5 FRONT RIGGING, DETACHABLE... 6 UPHOLSTERY... 7 ACCESSORIES...
Town: Postal code: Town: Postal code: CLIENT MEASUREMENTS. Seat Width in cm 38 cm 40 cm 42 cm 44 cm 46 cm. 40 cm
Front Castor Seat Depth in cm Deliver to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: E-Mail: E-Mail: Tel: Fax: Tel: Fax: Order date: Purchase order: Number required:
BENTLEY. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
Standard Base Price: 539
Manual Wheelchair Retail Prescription Form ACTION3JUNIORSMALL19102018 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer
STELLAR. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.
C u s t o m e r a n d O r d e r I n f o r m a t i o n Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v.072318 Shipping Address * * required F r a
TiLite. Please Fax to the TiLite Customer Service Team at or
- Print as guide for ordering DEALER INFORMATION ler: Adaptive Specialties RTS INFORMATION RTS: Email: SHIP TO INFORMATION Phone: Page 1 of 9 Email: TiLite Information Name: Ship Via: : Please Fax to the
Invacare Action 3 Junior Large Retail Max User Weight 80Kg (12.5 stone) Standard Base Price: 539 * Configurations may vary to the image shown
Manual Wheelchair Retail Prescription Form ACTION3JUNIORLARGE15112017 Tel: 01656 776222 Fax: 01656 776220 JAN 2018 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer Ref:
SEAT BACKREST. REAR SEAT HEIGHT SELECTION: independant of rear wheel size. Rear seat height in cm (2)
REAR SEAT HEIGHT SELECTION: independant of rear wheel size Rear Wheels 24" 25" Rear seat height in cm 37 38 39 40 41 42 43 44 45 46 47 48 49 50 (2) (2) The rear seat height can only be between 0 cm and
4.8. Name: K0005. Stem bolt Length /2 15 1/2 16 1/ /2 15 1/2 16 1/ /2 16 1/2 17 1/2
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:*
NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM.
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2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG
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MOVE ORDER FORM - CANADA
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:
1,795. Base Price. Part no.: CLIENT MEASUREMENTS. Town: Postal code: Town: Postal code: Tel: Fax: Tel: Fax: Purchase order:
Front Castor Seat Depth in cm Deliver to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: E-Mail: E-Mail: Tel: Fax: Tel: Fax: Order date: Purchase order: Number required:
Zippie TS SE November 2012 EIZ1A
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ORDER FORM Ver.6 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
C O L O U R S ZEPHYR EVERY DAY ORDER FORM Ver.6 Rev-091211 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
Max. user weight: 110Kg / 140kg USER WEIGHT Fax number: +44 (0)
Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: E-Mail: E-Mail: Tel: Fax: Tel: Fax: Order date: Purchase order: Number required: Marked for: Sunrise order no:
Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018
TRACER EX2 FOLDING WHEELCHAIRS Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018 PROVIDER NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS Invacare Canada
SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5
PARTS CATALOG CONTENTS SIDEFRAME AND CROSSBRACE... ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5 FRONT RIGGING, DETACHABLE... 6 UPHOLSTERY... 7 ACCESSORIES...
YOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP.
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APEX 4.6. FRONT Seat-to-floor height Caster sizes Height available +- 1/4" ORDER FORM - International. 3" Caster. Specify desired height:
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:*
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
Zippie Family. Album
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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:
C O L O U R S S PA Z Z - G ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
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UNMATCHED PERFORMANCE. THE PROFESSIONALS BEST CHOICE IN FOLDING ULTRA- LIGHTWEIGHT ABILITY.
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Condor Script Form Folding Frame Day Wheelchair 90050
90050 To Order Fill in the frame dimensions and features required. For variations describe in detail on a separate page. If you have any further questions contact us at the address at the bottom of the
Condor Script Form Folding Frame Day Wheelchair 90050
90050 To Order Fill in the frame dimensions and features required. For variations describe in detail on a separate page. If you have any further questions contact us at the address at the bottom of the
STELLAR GL. Order Form - USA Prices in U.S. Dollars. January 1, C u s t o m e r a n d O r d e r I n f o r m a t i o n.
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Zippie GS. Growth System
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