Quickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,
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1 Quickie QXi AADL EIF6, October 2018 Mark For: Submitting for: Date: PO#: Quote Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: Dealer Phone: ( Confirmation Confirm Via: PV: Fax: ( Address: PC: Address: Ship To City: Fax Option # Definition PV: Ship To Phone: ( Price Option # PC: Fax: ( Definition Price 1. FRAME 196WM78 Base Model Quickie QXi (Adjustable Axle 265 lbs For sizes use E1236 $2, Frame Style See Seat Height Matrix on page 2 196FS9 Standard Frame 196FS30 Hemi Frame 196TO38 Transit Transit System WC19 $ SIZE / SEATING Frame Width 196W5 196W6 196W7 196W8 196W9 196W10 196W11 17" 20" 196SL1 196SL6 Seat Sling Standard Seat Sling Omit Seat Sling 196QC01 196QC02 196QC03 Custom Seating Surefit Configurfit JayFit Seat Depth Frame Depths equals Seat Depths. 196SD7 196SD8 196SD9 196SD10 17" 196SD11 196SD71 196SD13 20" -$20.00 JAY Cushions (Optional To order any JAY cushions on-chair, please see the JAY price list. Quickie QXi, Ultra Lightweight Adjustable Folding Wheelchair Cushion name or part number must be filled out with desired width and depth JAY Bundled Cushion Price List 196JC20 Cushion Name or Part # Width: Depth: Quickie QXi featuring the Jay ION cushion Page 1
2 3. CASTERS / SEAT HEIGHT Front Seat Height Caster Stem Bolt See Front Seat Height Matrix & 13.0 only available w/ 60 hanger 196CS1 Standard 12.5" & 13" only available w/ Alum Angle Adj Footplate 196CS5 3/4" 196SH " 196SH " 196CS9 1 1/2" 196SH " 196SH " 196SH " 196SH " Front Seat Height Matrix 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 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 $ " Polyurethane 6" x 1.5" Semi Pneumatic $ " Polyurethane 8" x 1.5" Semi Pneumatic $ CF71 196CF12 196CF17 196CF23 Caster Fork 3.5" (standard stem bolt only 5.25" 6" 7" 4. REAR WHEELS / REAR SEAT HEIGHTS Rear Seat Height See Rear Seat Height Matrix 196RH9 196RH10 196RH11 196RH12 196RH13 196RH14 196RH15 196RH16 12" 12.5" 13" 13.5" 14.5" 15.5" 196RH17 196RH " 196RH19 17" 196RH " 196RH20 196RH " 196RH21 Rear Seat Height Matrix Rear Wheel Size Std Frame Hemi Frame 20" Rear Wheel 13.0" " 12.0" " 22" Rear Wheel 14.0" " 12.5" " 24" Rear Wheel 15.0" " 13.5" " 25" Rear Wheel 15.5" " 14.0" " 26" Rear Wheel 16.0" " 14.5" " Rear Wheel Tire See Rear Tire & Wheel Matrix for availability 196RT1 Pneumatic 196RT2 Pneumatic w/ Airless Insert $ RT3 Full Poly 196RT39 High-Pressure Clincher Black $93.00 Rear Wheel Size 196RT21 Schwalbe Marathon Plus Evolution See Rear Tire & Wheel Matrix for availability 196RW3 196RW8 20" Mag Wheel 22" Mag Wheel Handrim Natural Fit only available w/ 22, 24, 25 Lite Spoke. Plastic NA w/ 25, 26" 196RW1 24" Mag Wheel See Apendix for Rear wheel / Handrim matrix 196RW103 20" Mag Wheel 5 Spoke 196HR1 Aluminum Anodized 196RW104 22" Mag Wheel 5 Spoke 196HR4 Plastic $ RW102 24" Mag Wheel 5 Spoke 196HR22 Natural Fit - Standard Grip $ RW90 20" Lite Spoke Wheel $ HR23 Natural Fit - Super Grip $ RW91 22" Lite Spoke Wheel $ HR32 Natural Fit - No Thumb Grip $ RW92 24" Lite Spoke Wheel 196HR26 The Surge - Oval w/gription Strip $ RW93 25" Lite Spoke Wheel 196HR27 The Surge LT - Oval w/gription Strip $ RW94 26" Lite Spoke Wheel $ HR28 Q-Grip Neoprene Coated $ RW25 Omit -$43.00 Seat Squeeze Matrix Frame Depth Max Seat Squeeze 2.0" - 2.5" 17" - 2.5" - 20" 3.0" Page 2
3 4. REAR WHEELS / REAR SEAT HEIGHTS (CONT Rear Tire & Wheel Matrix 196AX1 196AX11 196AX45 Axle Quick Release Steel Quad Quick Release Steel NA on Spoke Threaded Axle $ $ AS4 196AS5 196AS6 Adjustable Axle Options Adjustable sleeve Fixed Sleeve 0⁰ Fixed Sleeve 3⁰ Center of Gravity Measure from front of back post to center of rear axle One Arm Drive 196CC2 1" Available only with 24" MBL Lite spoke wheels. Std Aluminum black handrim 196CC3 1.5" 196AL16 One Arm Drive Adj. Axle Plate $1, CC4 2" 196HM1 Right Hand Mount 196CC5 2.5" 196HM2 Left Hand Mount 196CC6 3" 5. 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 NA w/ Alum Angle Adj Front Mount footplates. 196H H H144 Elevating Hanger - Ext Mount NA w/ Alum Angle Adj Front Mount footplates. Elevating Hanger - Front Mount Only available w/ front mount alum angle adj footplates and -22" width Omit Hanger & Footplate $ $16.00 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 (-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 196BT B5 196B9 Back Type Standard Angle Adjustable Back $ Backrest Height Med (13"-17" Tall (-20" Push Handles Integral Push Handles, Folding Height Adjustable & Omit is 8 for Standard 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 -20" back height 196PH17 Folding Push Handle with Ht. Adj. Back $ PH2 Omit Push Handles Page 3
4 7. BACKREST / SEATING (CONT Back Upholstery 196BU1 Standard Upholstery 196BU88 Standard Upholstery EXO $ BU70 Backrest Tension Adj Ballistic Nylon *Reference 186BU70 for billing $ BU71 Backrest Tension Adj 3DX Vented *Reference 186BU71 for billing $ BU89 Backrest Tension Adj EXO *Reference XXXBU89 for billing $ BU14 Omit Back Upholstery -$ JB01 JAY Backs JAY Back (see Order forms Price List 196VU1 196VU2 196VU3 196VU4 196VU12 196VU5 196VU8 196VU9 196VU10 196VU11 196VU13 Military Service Patches US Marines Patch US Army Patch US Navy Patch US Air Force Patch US Coast Guard Purple Heart Purple Heart with Marines Patch Purple Heart with Army Patch Purple Heart with Navy Patch Purple Heart with Air Force Patch Purple Heart with Coast Guard 8. ARMREST / SIDEGUARDS Armrest - Padded Swing Away Some limitations when used with the Angle Adjustable Back in the rear most setting Please circle a setting, will default to 11" if no selection is made Padded Swing-Away STD (9" to 13" $ AA18 Setting 9" 10" 11" 12" 13" Armrest - Height Adjustable Flip Back HA Classic NA w / - depth 196AA AA105 Single Post Ht. Adj - Std (9.75"-14.75" Single Post Ht Adj - Low (8.25"-12.25" 196AA65 Flip Back Ht Adj LITE (10"- $ AA103 Dual Post Flip Back Ht Adj 196AA159 Flip Back Ht Adj Classic (11"- $ AA14 Omit Armrest 196AM23 196AM A01 196SG33 196SG29 Armpad - For Height Adjustable Desk Length (10" Full Length - Full ( Armrest Options Gel Cover For Swing Away Arms (pair Side Guards Plastic - Standard (8.5" High Plastic - Low (6.5" High $ $ KEY OPTIONS 196AT1 196A1 1961A01 196A A804 Anti Tips Spoke Guards Anti Tips (Pair $ A A02 Quickie Black Spoke Guard Quickie Clear Spoke Guard Pack Accessories Backpack - Black/Charcoal Adult $ Miscellaneous Seat Pouch Black $ A03 Caddy $ A2100 Crutch Holder $ Positioning Belt 1.5" Auto Buckle w/ Clamps $87.00 Positioning Belt Slide Clamps $ 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 196C142 Electric Blue 196C43 Mossy Oak Camouflage 196C143 Evergreen 196C42 Stars & Stripes 196C126 Glow Zebra (Choose above base color Std 196C144 Green Apple with White unless above base paint is 196C C147 Hot Sparkle Pink chosen NA 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 ( , Fax: ( C8 Yellow Page 4
5 APPENDIX Front Seat Height Matrix Cont. Lower Leg Length Range Matrix Page 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
Quickie QX December 2018
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:
Quickie IRIS January 2014
Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: ST: ZIP: Address: Dealer Phone: ( ) Fax: ( )
Quickie 2 January 2014
Mark For: Submitting for: Quote Order Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: ZIP: Dealer Phone: ( ) Fax: ( ) Address: Confirmation Email: Ship To City: ST: ZIP: Confirm
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
Quickie Q7 Adjustable March 2014
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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:
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:
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
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
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 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 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:
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
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
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:
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
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:
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
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
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
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
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
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
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
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:*
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
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:
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. 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
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
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
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
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:*
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:
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
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:*
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
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
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:
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
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
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:*
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:
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.
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:
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:*
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:*
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:
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:*
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
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
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.
4.2. Ship to: Vendor: Name: Date: Address: Ordered by: 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 orders@motioncomposites.com www.motioncomposites.com 4.2 MOVE ORDER FORM - CANADA
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
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
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
4.8. A6MA085 Italian Manual. 3" caster 4" caster. 8" caster Stem bolt Length. + 2,54 cm 1" + 5,08cm 2" STD. 36,8cm 14,5" 34,3cm 13,5" 39,4cm 15,5"
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 - INTERNATIONAL P.O.
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
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
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
C2 FRONT Seat-to-floor Height - Please select your choice. Custom Technologies Limited. 40 Raywood Crescent TAUPO. New Zealand
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.
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
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:
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:
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
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
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
Helio A6 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 4.7 Helio A6 ORDER FORM - CANADA P.O. number:*
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:
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:
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:
4.6. A7 FRONT Seat-to-floor Height - Please select your choice. Stem bolt Length /2 15 1/2 16 1/2
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:*
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 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:
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
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:
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
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
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:
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
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:
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...
4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required KDMA063 English Manual (STD) Manuel Français
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:*
NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM.
LITTLE WAVE NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM. EVOLVING AND GROWING WITH YOUR CHILD Seat height, width, depth, CG, caster wing position, seat upholstery, seat pans the most built in adjustment
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
Helio A6 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 Helio A6 ORDER FORM - CANADA P.O. number:*
LIGHTWEIGHT FOLDING & SUPERIOR PERFORMANCE
LIGHTWEIGHT FOLDING & SUPERIOR PERFORMANCE XENON 2 LIGHTWEIGHT, HIGH-PERFORMANCE, FOLDING SERIES WHETHER YOU RE LOOKING FOR THE VERY BEST IN DRIVING DYNAMICS OR THE MOST COMPACT FOLDING DIMENSIONS, THERE
Product. QUICKIE QRi PAGE 1
PAGE 2 QUICKIE QRi Product QUICKIE QRi PAGE 1 Category... 1 Product... 1 QUICKIE QRi... 5 BASE FRAME... 5 FRAME... 5 FRAME... 5 TRANSIT KIT... 6 AXLE PLATES AND AXLES... 7 QUICK RELEASE AXLES MATRIX-Q7/QRI/ZONE...
Stallion Script Form Fixed Frame Adjustable Wheelchair 90100
90100 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
LIGHTWEIGHT FOLDING & SUPERIOR PERFORMANCE
LIGHTWEIGHT FOLDING & SUPERIOR PERFORMANCE XENON 2 LIGHTWEIGHT, HIGH-PERFORMANCE, FOLDING SERIES WHETHER YOU RE LOOKING FOR THE VERY BEST IN DRIVING DYNAMICS OR THE MOST COMPACT FOLDING DIMENSIONS, THERE
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