SHIPPING INFORMATION. Order
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1 Size 3 Order Form MASS 2014 Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Pride Mobility Products Aust Pty Ltd Apollo Drive Hallam VIC 3803 Ph: Fax: Date: Provider Acct #: Provider: Provider Contact: Prov. Address: Provider City: ST: ZIP: Attention: Address: SHIPPING INFORMATION Provider Phone: ( ) Fax: ( ) Ship To City: ST: ZIP: Confirmation Quote Order PO#: Ship To: Address: Ship To Phone: ( ) Fax: ( ) DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. HCPCS codes should not be considered as legal advice. All prices Mark For: MEASUREMENT WORKSHEET Age: Height: ft. in. ROCK Size 3 chair, Tilt-in-Space Includes: Tilt in space, dynamic, mobility base, Silver metallic frame color, standard configuration. Weight: lbs. K E1161 ROCK Chair - Size 3 A. Sitting Depth B. Trunk Depth C. Trunk Width D. Hip Width E. Top of Shoulder to Seat Figure 1 - Client Measurements F. Lower Leg Length Transit Option Seating System and Back System Required for WC19 Occupied Status.Transit Option must be factory installed and is not retrofitable Transit Option Call for "back canes only" special transit configurations. Reaction Dynamic Seating - Std Requires Angle Adjustable Leg Rests Upholstery Color KRC302 E2295 REACTION Dynamic Component Upper Body Spring Selections C Soft - Pair N/C C Medium - Pair C Hard - Pair N/C Upholstery Color applies to: back cushions lateral pelvic/thigh supports 306 Black/Sport Mesh 311 Vibrant Red/Black/Sport Mesh N/C 309 Purple/Black/Sport Mesh N/C 310 Teal/Black/Sport Mesh N/C Front Rigging Required with REACTION Dynamic Seating System E0990 Angle Adjustable Leg Rest Required when ordering KRC302 Active Seating Accessory. Knee angle adj. 18 incr. w/press of button. allows active movement of lower leg. Lower Body Spring Selections C Soft - Pair N/C C Medium - Pair C Hard - Pair N/C Page 1 of 6
2 Foot Plate Requires Front Rigging Selection Fixed Foot Plate N/C K0040 Quick Angle Adj. Flip-Up Foot Plate -18 to +45 Dorsal/Plantar Flexion. 8 Positions. ROCK 3 Adjustable Depth Seating System K " Adj. Depth Seat Pan Kids UP LifeForm Contoured Seat Cushion Selections Seat Cushions Incl: 2 Positioning Wedges, Abductor Wedge; Black Mesh Cover Ischial Insert Selection Required E " Width, 14-17" Depth C (14") Open Cell Foam E " Width, 14"-17" Depth C (17") E " Width, 17"- 20" Depth C (14") C (17") K0108 Soft Memory Foam C (14") C (17") K0108 Medium Memory Foam Kids UP LifeForm Seating System Accessories Extra Positioning Wedges (4) Wedge for Seat Cushion Pressure Relief Layer - Soft (14" x 8" x 1") Memory Foam (17" x 20" x 1/2") Wedge for Seat Cushion (17" x 9" x 1") Synergy Seat Cushion Options CUSASMB1190 E2607 Synergy Solution Cushion 14"x12" CUSASMB1004 E2607 Synergy Solution Cushion 14"x14" CUSASMB1005 E2607 Synergy Solution Cushion 14"x16" CUSASMB1006 E2607 Synergy Solution Cushion 14"x18" CUSASMB1007 E2607 Synergy Solution Cushion 16"x16" CUSASMB1966 E2607 Synergy Solution Cushion 16"x17" CUSASMB1008 E2607 Synergy Solution Cushion 16"x18" CUSASMB1967 E2607 Synergy Solution Cushion 16"x19" CUSASMB1009 E2607 Synergy Solution Cushion 16"x20" CUSASMB1968 E2607 Synergy Solution Cushion 17"x16" CUSASMB1248 E2607 Synergy Solution Cushion 17"x17" CUSASMB1969 E2607 Synergy Solution Cushion 17"x18" CUSASMB1249 E2607 Synergy Solution Cushion 17"x19" CUSASMB1970 E2607 Synergy Solution Cushion 17"x20" CUSASMB1801 E2603 Synergy Solution 1 Seat Cushion 14"x14" W/Gel Layer CUSASMB1802 E2603 Synergy Solution 1 Seat Cushion 14"x16" W/Gel Layer CUSASMB1803 E2603 Synergy Solution 1 Seat Cushion 14"x18" W/Gel Layer CUSASMB1804 E2603 Synergy Solution 1 Seat Cushion 16"x16" W/Gel Layer CUSASMB1805 E2603 Synergy Solution 1 Seat Cushion 16"x18" W/Gel Layer CUSASMB1806 E2603 Synergy Solution 1 Seat Cushion 16"x20" W/Gel Layer CUSASMB1807 E2603 Synergy Solution 1 Seat Cushion 17"x17" W/Gel Layer CUSASMB1808 E2603 Synergy Solution 1 Seat Cushion 17"x19" W/Gel Layer Pride Mobility Produccts. ROCK3 REV. 11/2013 Page 2 of 6
3 ROCK 3 Back System Options E2293 Configurable, Contoured, Adjustable Height Solid I-Back System Kids UP Lifeform Back Cushion Options Select 1 if is Selected. Back Cushions include contouring wedges and lumbar support C 18"-23" Contoured Back Cushion. (I-Back) C 22"-26"" Contoured Back Cushion. (I-Back) C Basic Fixed Height Armrest 12" Thin Profile - Pair Armrest Options E0973 Adjustable Height Armrest Thin Profile Pad - Pair E0950 Upper Extremity Positioning Platform Color - Clear Tray - incl clear tray & h/ware E0950 Upper Extremity Positioning Platform Color - Gray Angle/Depth Adj. Support Hardware - Req. for all trays ROCK 3 Padded Tray Cover Rear Wheel Options X0D18C 18" Composite Rear Wheels X0D24C 24 Composite Rear Wheels. Requires angle adjust system Rear Tire Options X Full Polyurethane w/treads Page 3 of 6
4 Rear Anti-Tips E0971 Rear Anti-Tips with Wheels (Pair) Hand Rims Axle Plate for 24" Wheels Required DXXC Chrome Hand Rims N/C Adj. Position Axle System DXXC Plastic Coated Hand Rim Casters C 8" x 2" Poly Casters N/C Lateral Pelvic/Thigh Supports L E0956 Left Pelvic/Thigh Support Pkg R E0956 Right Pelvic/Thigh Support Pkg. Lifeform Anterior Pelvic Positioning Belts Medial 4-point pelvic positioning belt recommended with REACTION seating. Positioning belts not for use as a occupant restraint during transit in a motor vehicle E0978 LifeForm 2-point 1" Metal PB Buckle, 3.5" pads E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 3.5" pads E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 4.5" pads E0978 LifeForm 2-point 1.5" Metal PB Buckle, 6.5" pads E0978 LifeForm Medial 4-point 1.5" Metal PB Buckle, 6.5" pads Lifeform Anterior Trunk Support Anterior Trunk Supports not for use as a occupant restraint during transit in a motor vehicle. LifeForm Zipper Opening Dynamic E0960 Zipper Opening - S E0960 Zipper Opening - M E0960 Zipper Opening - L LifeForm Zipper Opening Structured E0960 Structured Zipper Opening - S E0960 Structured Zipper Opening - M E0960 Structured Zipper Opening - L Lifeform Swing-Away Abductor Hardware and Pads 4-way stretch cover included with Lifeform Abductor pads E1028 ROCK 3 S/A Abduct. Hardware E0957 Small Wedge(2"-3"W x 4"L x 3"D) Page 4 of E0955 Med. Wedge (2"-4.5" x 5"L x 3"D) E0955 Lg. Wedge (3"-5" x 5"L x 4"D)
5 Lifeform Headrest and Support Hardware - choose pad size incl h/ware E0955 8" Curved Oval Pad E1028 LifeForm Removable Headrest E " Curved Oval Pad Mounting Hardware (Required for all Headrest Options) E " Curved Oval Pad * Universal Head Rest Mount Plate Only* E0955 Narrow Adjustable Arc Pad E0955 Standard Adjustable Arc Pad *Accomodates several other manufacturers headrests. Call for details. Lifeform Ankle and Foot Positioning - choose type & size LifeForm Hard Side Foot Stabilizers - LifeForm Ankle Hugger Foot Stabilizers - N/C L K0108 Left - Medium - 4"W L K0108 Left - Medium - 4"W R K0108 Right - Medium - 4"W R K0108 Right - Medium - 4"W L K0108 Left - Large - 5"W L K0108 Left - Large - 5"W R K0108 Right - Large - 5"W R K0108 Right - Large - 5"W Lifeform Swing Away Lateral Support Hardware - choose brkt style & pad type & size Choose your bracket and CURVED pad size Choose your bracket and PLANAR pad size L E0956 Left 1.5" pediatric bracket lateral thoracic support package, L E0956 Left 1.5" pediatric bracket lateral thoracic support package, Planar Pad R E0956 Right 1.5" pediatric bracket R E0956 Right 1.5" pediatric bracket Planar Pad L E0956 Left 2" bracket lateral thoracic support package, L E0956 Left 2" bracket lateral thoracic support package, Planar Pad R E0956 Right 2" bracket lateral thoracic support package, R E0956 Right 2" bracket lateral thoracic support package, Planar Pad Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose Swing-Away Hardware (required) Choose Swing-Away Hardware (required) Requires , 3120, 3210, Requires , 3120, 3210, L E1028 Left 1.5" DoubleSwing R E1028 Right 1.5" DoubleSwing L E1028 Left 2" DoubleSwing R E1028 Right 2" DoubleSwing L E1028 Left 1.5" DoubleSwing R E1028 Right 1.5" DoubleSwing L E1028 Left 2" DoubleSwing R E1028 Right 2" DoubleSwing LifeForm 1.5"Swing-Away Width and Depth Ext.(optional) Options Available only with Swing-Away Hardware L Depth Ext. + 1", pediatric, Left N/C L Depth Ext. + 1", 2" Brkt., Left N/C R Depth Ext. + 1", pediatric, Right N/C R Depth Ext. + 1", 2" Brkt., Right N/C L Width Ext. + 1", pediatric, Left N/C L Width Ext. + 1", 2" Brkt., Left N/C R Width Ext. + 1", pediatric, Right N/C R Page 5 of 6 LifeForm 2"Swing-Away Width and Depth Ext.(optional) Options Available only with Swing-Away Hardware. Width Ext. + 1", 2" Brkt., Right N/C
6 Choose your bracket and CURVED pad size L E0956 Left 1.5" fixed pediatric bracket LifeForm Fixed Lateral Support Hardware Choose your bracket and PLANAR pad size L E0956 Left 1.5" fixed pediatric bracket Planar Pad R E0956 Right 1.5" fixed pediatric bracket R E0956 Right 1.5" fixed pediatric bracket Planar Pad L E0956 Left 2" fixed bracket lateral thoracic support package, L E0956 Left 2" fixed bracket lateral thoracic support package, Planar Pad R E0956 Right 2" fixed bracket lateral thoracic support package, R E0956 Right 2" fixed bracket lateral thoracic support package, Planar Pad Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Accessories Life Support Accessories NOT tested with Transit. Must remove prior to tie down K0105 IV Support Pole E E2208 Oxygen Tank Holder E1029 Ventilator Tray for LTV Ventilator Series Only Requires 18" Rear Wheels Battery/Vent. Accessory Tray Requires 18" Rear Wheels (Does not include vent. mount for LTV) Underchair Cargo Tray (carries up to 10lbs) Rock 3 Sunshade Replacement Contoured Seat Cushion Covers E "w x 17"d Seat Cushion Cover Only E "w x 17"d Seat Cushion Cover Only E "w x 20"d Seat Cushion Cover Only Custom Notes: Additional Extras R R R R R R Upper Body - Soft - Pair Replacement Springs Upper Body - Med - Pair Upper Body - Hard - Pair Lower Body - Soft - Pair Lower Body - Med - Pair Lower Body - Hard - Pair Page 6 of 6
SHIPPING INFORMATION Provider Acct #:
May 2014 Kid's ROCK TM Size 3 Order Form Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
SHIPPING INFORMATION Provider Acct #:
May 2014 Kids ROCK TM Size 2 Order Form Maximum Weight Capacity 115 lbs. 14"Wx16"Dx22"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
SHIPPING INFORMATION Provider Acct #: Address: ST: ZIP:
May 2014 Kids FAST Order Form Maximum Weight Capacity 80 lbs. 12"Wx14.5"Dx19.5"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
Convaid Trekker 2 - HCPCS E1234 Retail Price List / Order Form
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Convaid Trekker 2 - HCPCS E1234 Canadian Retail Price List / Order Form
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R82 x:panda. USD Retail Price List/ Order Form. Account #: Purchase Order No.:
Account #: Purchase Order No.: Contact: R82 x:panda USD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US Configuration
x:panda, size 1, med. back X c x:panda, size 1, med. seat 7¼" X c
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R82 x:panda. USD Retail Price List/ Order Form. Account #: Purchase Order No.:
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Account Information Date Account Number Branch Dealer Contact Phone Fax Email Address PO Number Mark For Ship To Information [ ] Quote [ ] Order Shown with Optional Equipment Standard Features Name Address
R82 Kudu - E1233. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features:
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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: ( )
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Quantum Q6400Z Series Group 4 Order Form 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866)
R82 Stingray. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: City/State/Zip: Effective: 2/01/ Rev 7.
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R82 Stingray - E1233
Account #: Purchase Order No.: Contact: R82 Stingray - E1233 USD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US
Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA Sales: Phone: (866) Fax: (866)
This product is available for purchase online at www.mypride.com Account #: Date: Order No. Fax No. Phone No. PAGE 1 Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Sales: Phone:
Quickie IRIS FSS Net Order Form/Price List (SIN F-1)
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Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
Quantum 6400Z Series Group 4 Single Power & Multiple Power Order Form 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone:
FUZE T50. 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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Phone: Nov-17
By Ormesa New 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List in USD Phone: 800-327-0681 Nov-17 Fax: 260-665-3047 Email: iim@mobility-usa.com Quote: P.O. www.mobility-usa.com Bill To
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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
Basic price 2.250,- Excl. VAT
Date Invoice address Invoice address = delivery address Customer code C- Contact person Reference Other delivery address Quote Seat width D64035 35 cm D64040 40 cm D64045 45 cm D64050 50 cm = Standard
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
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FUSION Seating Prescription Form Custom Built Seating System
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Quantum 1450 Group 3 Single Power Order Form Up To 600lbs Weight Capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax:
C300 Corpus Tilt. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
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FUZE T20. 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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MASS Script Form. Frame. Backrest. Seat Depth. Tsunami ALX K0005 Charge. Sling Position. Seat Width / Seat Depth. Seat Width.
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Phone: Jan 17. Fax: usa.com Quote: P.O. usa.com Bill To
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Quantum 600 Series Group 3 Single Power & Multiple Power Order Form/ODJFS Only 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA
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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:
Quantum Rehab A Division of Pride Mobility Products Corporation
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2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) PRO-CG. Adult Manual Wheelchair
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2016 EZ RIDER UPRIGHT PRODUCT PPT
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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
KID-KART TLC... 3 BASE... 3 BASE - Discontinued... 3 SILVER BASE... 4 CASTER FORK ASSEMBLIES... 5 WHEEL LOCKS... 6 ANTI-TIPS... 7 REAR WHEELS...
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2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG. Adult Manual Wheelchair
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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.070118 Shipping Address * * required F r a
STELLAR. 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.
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
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
Velocity Order Form. Dealer Information Dealer Name ATP Account Number Phone Fax Date PO# Ship to Address City State Zip
1-800-963-7487 Fax: 239-772-3252 Velocity Order Form Dealer Information Dealer Name ATP Account Number Phone Fax E-Mail Date PO# Ship to Address City State Zip Client Information Weight Height Seat-to-Floor
Convaid, the company that invented the adaptive assisted wheelchair, has helped special
2014 www.convaid.com Convaid, the company that invented the adaptive assisted wheelchair, has helped special needs children and their families live fuller, more productive lives since 1976. Convaid produces
INDUSTRIES, INC. PRODUCT CATALOG C121
METALCRAFT INDUSTRIES, INC. Note About Digital Catalog Note About Digital Catalog Text In This Digital Catalog That Are Highlighted Are Linked To Other Parts Of The Highlighted Text In This Digital Catalog
Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.
AADL W659/W991 Quantum Q6 Edge Z with TB3 Power Positioning FOR AADL USE ONLY Pride Mobility Products Co. 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Discount:
CUSTOM INCEPTION CUSHION ORDER FORM HCPC CODE: E2609
CUSTOM INCEPTION CUSHION ORDER FORM HCPC CODE: E2609 CUSTOMER/PATIENT INFORMATION Date: Company Name/ACCT #: Patient Name: Patient Weight: Patient Height: P.O. Number: Requested By: Phone: Email: Ship
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
Customer code C- Invoice address. Max. 90 kg See page 5 Side upholstery (reduces SW with 2 x 2 cm) = Standard equipment
Date Customer code C- Invoice address Contact person Reference Other delivery address Quote Invoice address = delivery address Basic price: 3.495,- excl. VAT Seat width D2025 D2030 D2035 25 cm 30 cm 35
Canadian Suggested Retail Price List April 2015
Size 5 Canadian Suggested Retail Price List April 2015 Account No. Drop Ship: Date: Name P.O. Number: Address Buyer: City Marked For: State Zip E Mail: Tel. Fax A ( Back height) B (Arm height) C (Lower
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
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
The order form has (MSRP) retail prices, but your price is at least 25% less than retail price. Multiply retail by.75 or call or for a quote.
The order form has (MSRP) retail prices, but your price is at least 25% less than retail price. Multiply retail by.75 or call or email for a quote. The order form has (MSRP) retail prices, but your price
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
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:
R82 Caribou - E0641. Retail Price List/ Order Form. Account #: Purchase Order No.: Date: Caribou Standard Features:
Account #: Purchase Order No.: Date: Contact: R82 Caribou - E0641 Retail Price List/ Order Form Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Caribou
BREEZY EC WHEELCHAIRS. The best combination of durability, selection and value.
BREEZY EC WHEELCHAIRS The best combination of durability, selection and value. Breezy EC 2000 A quality wheelchair with options offering the flexibility to accommodate a variety of users. Standard Features
Quantum 1103 Ultra Series Group 2 Single Power Order Form 200 lbs weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum 1103 Ultra Series Group 2 Single Power Order Form
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
Quantum Q1121 Series Group 3 Single Power and Multiple Power Order Form 300 lbs. weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum Q1121 Series Group 3 Single Power and Multiple Power
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
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
Invacare Action 3 NG Transit Retail Max User Weight 125Kg (19.7 stone)
Manual Wheelchair Retail Prescription Form ACTION3NGTRANSIT10112016 Tel: 01656 776222 Fax: 01656 776220 JAN 2017 Email: ordersuk@invacare.co.uk Online Spares available at www.invacare.co.uk Customer Ref:
Quickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,
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:
Adjustable Height Raised Toilet Seat Model 101 RTS Pricelist/Order Form December 2014
Adjustable Height Raised Toilet Seat Model 101 RTS Date: Name: P.O.#: Address: Name: City/State/Zip: Mark For: Phone: Account #: Fax: This Activeaid raised toilet seat is unique in its design to accommodate
Convaid, the company that invented the adaptive assisted wheelchair, has helped special
2014 www.convaid.com Convaid, the company that invented the adaptive assisted wheelchair, has helped special needs children and their families live fuller, more productive lives since 1976. Convaid produces
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:
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG
P.R.O. CG 2241 N Madera Rd Simi Valley, CA 93065 Phone: (800) 331-8551 Fax: (888) 582-1509 www.freedomdesigns.com Date: PO# Adult Manual Wheelchair TM SE Date: Buyer: Company: Email: Quote Order PO# Location:
Complement your Zippie with the JAY Zip Cushion and Back designed just for kids! Pediatric Wheelchair Portfolio
4 Complement your Zippie with the JAY Zip Cushion and Back designed just for kids! Pediatric Wheelchair Portfolio JAY Zip Back Versatile One Step Release Hardware Easy one step release Fits on wide range
M1 - NPO. Dealer Information. Client Information. Client Measurements
Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified
Manufacturer: Model: Seat width: cm Seat depth: cm
Thompson House Unit 10, Styles Close, Sittingbourne, Kent ME10 3BF Tel: 01795 477280 Fax: 01795 229692 Email: sales@rms-kent.co.uk web: www.ineedawheelchair.co.uk Caddy modular seating system order form
Vision Ultra-single power
Account # Dealer Name Contact Phone Date Fax E-Mail PO Number Ship to Address City State Zip *HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers
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
AT MSRP Price List. Description. HCPCS Code K0020 K0020 K0106 K0106. Part Number AP3 AP4 GAP GAPS 1386/87 FUA PT0031
Client: P.O.#: AT MSRP List AP3 AP4 GAP GAPS 1386/87 FUA PT0031 3 x 12 Desk Length Leatherette 4 x 16 Tapered Leatherette Standard Height Adjustable, Removable Armrest Flip-Up Armrest Left $37.50/ea. $164.00/ea.
Frame. Pos Item number Description Comment
Titel - 1 - Titel - 2 - Table of Content Zippie Voyage... 4 Basic Equipment... 4 Frame... 4 Slide-N-Lock Interface... 5 Transit Kit... 6 Canopy... 7 Seat, Back... 8 Seat Base... 8 Seatback... 10 Seat Cushion...
BEARINGS BEARINGS
TIRES PNEUMATIC.... 1-4 SNAP ON.....4 PRIMO HIGH PERFORMANCE......5-6 SCHWALBE HIGH PERFORMANCE.....5-6 KENDA HIGH PERFORMANCE... 7 MAINTENANCE FREE TIRES SHOX URETHANE TIRES..... 8 URETHANE TIRES....
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
Canada Quote / Order Form Combi
Canada Quote / Order Form Combi 7105 Northland Terrace Brooklyn Park, MN 55428 Ph# 1-888-538-6872- Ext 2 Fax# 763-582-0442 Amy Jorgensen-Inside Sales AmyJ@danetechnologies.com www.levousa.com Dealer Information
MEDIchair Northern BC nd Avenue Prince George, British Columbia V2L 3A6 Toll Free
MEDIchair Northern BC 849 2 nd Avenue Prince George, British Columbia V2L 3A6 Toll Free 1-800-330-2772 BC Ministry of Health A Cheat Sheet for Clinicians Included Features for a Basic Wheelchair, Basic
R82 Rabbit Up - E0638 / E0642 USD Retail Price List/ Order Form
R82 Rabbit Up - E0638 / E0642 USD Retail Price List/ Order Form Account #: Purchase Order No.: Date: Contact: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip:
Multi Bari. Key features at a glance: Additional options:
Multi Bari 2 Multi Bari Designed for comfort and pressure management control, the Multi Bari has removable waterfall back cushions that can be individually positioned and re-positioned for comfort with
Bio-ST ST & ST-HD. Modifications Removable and/or Additional Foam Shape Contour Covers A A A A & A
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: E-Mail: Inside Contact: Phone: Fax: E-Mail:
Quantum 1103 Ultra Series Group 2 Static Seating Order Form 300 lbs. weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum 1103 Ultra Series Group 2 Static Seating Order Form
Product List V Adaptive Engineering Lab 102 E Keefe Ave Milwaukee, WI 53212
Product List V2016.1 Adaptive Engineering Lab 102 E Keefe Ave Milwaukee, WI 53212 P: 866.656.1486 F: 866.656.1487 E: sales@aelseating.com W: AELseating.com Published August 1, 2016 TABLE OF CONTENTS >Positioning
Tailored seating solutions for the user requiring a custom CONFIGURED product with the ultimate personal FIT.
C ONFIGUREF IT Tailored seating solutions for the user requiring a custom CONFIGURED product with the ultimate personal FIT. Alignment to Reimbursement: Ease of Ordering: Improved and Expanded Product