C300 Corpus Tilt. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
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1 * Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Address: Client Information Permobil recommends that the client is evaluated by a certified rehab specialist. * First Name: * Last Name: Diagnosis: Funding Source: Client Age: Client Measurements * Weight: *Height: A) Top of Shoulders: B) Chest Depth: C) Chest Width: D) Seat Depth: E) Top of Head: F) Elbow to Hand: G) Seat Pan to Elbow: H) Hip Width: *I) Knee to Foot: Three column pricing on order/quote: Display HCPCS Codes on order/quote: Please send order/quote to fax#: (800) to: sales@permobilus.com Permobil Inc Eastgate Blvd. Lebanon, TN Tel: (800) Fax: (800) Prices effective March 8, 2010.
2 Chair Model and Colors I C300 Base Corpus VR2 - C300 PS1 6, K0856 Price Includes: FWD C300 Power Base Set Up Power Tilt, Shock Absorbing Suspension System, VR2 Advanced Controller, Tie Down Hardware for Strap Systems, Anti-Tippers, Charger, Tri-Spoke Split Rim with Flat Free Drive Tires, Platinum Silver Hubcaps, and Standard Positioning Belt. Substitution of items from other order forms is not allowed on this configuration. I C300/K300 Shroud - Onyx Black I C300/K300 Shroud - Crystal Blue Base Options IM34 SLDG - REQDBatteries - Group 34, 12V 60 Amp Hrs, Installed K0108 Batteries MUST be selected with this configuration I Fixed Seat Tube for Tilt I Power Adjustable Seat Height - 8" Travel 2, E2300 To assist in transfers and improve access for function. I P+ PP1A Programmer - VSI, VR2 or Pilot+ Controllers Joystick Options I VR2 Advanced Joystick Non expandable joystick capable of controlling tilt and a seat elevator through the joystick. I10045 Cone Shaped Joystick Knob - Standard. I Chin Cup For Joystick Knob E2324 I "T" Handle For Joystick Knob E2323 I "Large Ball" For Joystick Knob E2323 I "Softball" For Joystick Knob E2323 I "Mushroom" For Joystick Knob E2323 I "Stick" For Joystick Knob E2323 IPC101B Bodypoint J/S Handle 3" U-Shaped w/ Flex-Shaft E2323 IPC102B Bodypoint J/S Handle 4" U-Shaped w/ Flex-Shaft E2323 IPC107B Bodypoint J/S Handle Dome Shaped, Rubber E2323 I10468 Joystick Mount Right - Fixed, VR2 I10469 Joystick Mount Left - Fixed, VR2 I10470 Joystick Mount Right - Swing Away, VR E1028 I10471 Joystick Mount Left - Swing Away, VR E1028 Page 2 of 7
3 I Retractable Joystick Mnt Right - R-net, VR2 Only E1028 I Retractable Joystick Mnt Left - R-net, VR2 Only E1028 Seating System This Configuration of the Corpus Seat Includes: Corpus Seat Frame, 45 CG Power Tilt, Manual Recline, Manual Elevating Non-Articulating Legrests, 14"L Leatherette Armrests, Height Adjustable Armrest Assembly with Arms Mounted in the Tall Position, and Two Piece Corpus Footplates. User Weight Limit = 265 lbs. I Corpus Seat with 45 CG Pwr Tilt & Manual Recline 6, E1002 Includes 45 Center of Gravity Tilt and Manual Adjustable Backrest Angle. Seating System Options I10509 Single Seat Function Ctrl Kit - C300 Tilt Only 1, E2310 This item must be selected. For operation of a single seat function through the wheelchair electronics via the VR2 Advanced Joystick Module. I Remote Stop System VSI, VR2, Safegate Consists of a Radio Frequency (RF) handheld transmitter and an RF receiver mounted on the wheelchair. Each transmitter and receiver is a serialized matched pair, meaning they must be used together. Custom charge may be required if ordering with a low backrest height or a pediatric wheelchair. If ordering Remote Stop System with a K450, push handles must also be selected. Backrest Options BACKREST HEIGHT NOTE: Backrest heights are measured from the seat pan to the top of the backrest shell with the backrest set at 90. I Ergo Back Fixed 14" W x 21" H - Leatherette E2620 I Ergo Back Fixed 14"W x 26.5" High - Leatherette E2620 I Ergo Back Sliding 16"W x 21"H - Leatherette E2620 I Ergo Back Sliding 16"W x 26.5" H - Leatherette E2620 I Ergo Back Sliding 18"W x 21"H - Leatherette E2620 I Ergo Back Sliding 18"W x 26.5"H - Leatherette E2620 I10472 Solid Back 16"W x 26.5"H - C300 Corpus Tilt Only Includes Fixed Mounting Hdw, Lateral Wedges, Leatherette Cushion, and Lumbar Pads. I10473 Solid Back 18"W x 26.5"H - C300 Corpus Tilt Only Includes Fixed Mounting Hdw, Lateral Wedges, Leatherette Cushion, and Lumbar Pads. Page 3 of 7
4 I10318 ROHO Backrest Cushion For Ergo Back Price Includes: ROHO MID PROFILE Backrest Cushion which will be matched to fit the Ergonomic Backrest that you select. Approximate height of MID PROFILE cells is 3" in their inflated state. Also includes a Mesh Cover for the ROHO Backrest Cushion, Hand Pump, and Patch Kit. This will NOT fit these part numbers: (I10004, I10005, I10111, I10112, I ). Please indicate below if you would like to OMIT the Ergo Back Cushion. I10319 ROHO Backrest Cushion For Ergo Back - Notched Recommended ROHO cushion when ordering Lateral Trunk Supports. Please indicate below if you would like to OMIT the Ergo Back Cushion. I10320 Omit Ergonomic Backrest Cushion Seat Sizing I Corpus Seat 17"W x 18"D I Corpus Seat 17"W x 20"D I Corpus Seat 19"W x 18"D I Corpus Seat 19"W x 20"D I10038 Ergonomic Seat Cushion Leatherette E2601,E2602 Not available with seat widths less than 16" or seat depths less than 14". Armrest Options I10016 Height Adjustable Armrest Assembly - No charge with power tilt and/or recline. I "x14" Corpus Arm Left - Dual Taper, Leatherette I "x14" Corpus Arm Right - Dual Taper, Leatherette I Armrest Mount High Range of adjustment in high position is 11" " measured from the seat pan to the top of the armrest pad. I Corpus Armbar for 18" Btw the Arms - Installed I10001 Corpus Armbar for 20" Btw the Arms - Installed I Armrest Height Ext (+2") I Armrest Pouch-Right I Armrest Pouch-Left Legrest Options I Legrest Assm. 2pc Footplates (Complete) I Manual Adjustment Legrest Elevation Page 4 of 7
5 I10474 UT Calf Support Kit (J) w Mesh Cover & Adj Hardware E1028 5"W x 6.5"T Pad. I UT Calf Support Kit (H) w Mesh Cover & Adj Hardware E1028 7"W x 7"T Curved Pad. Accessories I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium I10404 Bodypoint Padded Hip Belt UniTrack (C300) - Medium K0108 I10402 Bodypoint Non-Padded Hip Belt, UniTrack - Large K0108 I10408 Bodypoint Padded Hip Belt UniTrack - Large K0108 I Positioning Belt Retractable K0108 I Positioning Belt Retractable Long K0108 I Headrest for Ergo Back w/ Curved Mount Brkt - Leath E0955 Must also select PN I This part consists of a leatherette headrest pad (10"W x 5"T) I with a 10"L slotted, curved mounting bracket. UT Ergo Headrest w/ Black Fabric Cover E0955 Must also select PN I I UT Lateral Adjustment Bar for UniTrack Headrest Allows for approximately 4" of lateral adjustment to the UT Ergo Headrest either right or left. NOTE: Due to the width of this item (approx 9"), it may be necessary to send other items such as back pack clips unmounted. Custom charge may apply with lower back heights. IHEADADAPTER Universal Headrest Adapter K0108 For aftermarket headrests. I10552 Adj Removable - Headrest Hardware (1 Each) E1028 I UT Amp. Support Pad (H) w/ Mesh Cover - (1 Each) E1020 7"W x 7"T Curved Pad. Must also select PN I I UT Amp. Support Pad (D) w/ Mesh Cover - (1 Each) E1020 8"W x 8"T Flat Pad. Must also select PN I I10553 Adj Removable - Amp Support Hardware (1 Each) E1028 Please indicate if you would like the amputation support mounted on the right or left side of the seat frame: Mount Amp Suppt on Right: Mount Amp Suppt on Left: I UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair) E "W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I I UT Thigh/Hip Suppt (C) w/ Mesh Cover - High (Pair) E0956 8"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I I UT Thigh/Hip Suppt (G) w/ Mesh Cover - High (Pair) E "W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I I10550 Adj Removable - Thigh Support Hardware (Pair) E1028 I Lateral Supports Std. Leatherette-ErgoBack Only E0956 Must also select PN I I Swing Away Trunk Supports Leatherette-For Ergo Back E0956 Must also select PN I I10551 Adj Removable - Trunk Support Hardware (Pair) E1028 I Transfer Handles for UniTrack Accessory Rail I Push Handles for Ergo Backrest Order with Ergonomic or Rectangular Backs. Custom charge may apply if ordering push I handles with an articulating vent tray. Medical Necessities Bag Includes Medical Necessity Bag Clips (Carabiner Style). I Medical Necessity Bag Clips - Carabiner Style Page 5 of 7
6 I Upper Extremity Support Small, Angle Adjustable E0950 I Upper Extremity Support Angle Adjustable. 14" W E0950 I Upper Extremity Support Angle Adjustable. 16" W E0950 I Upper Extremity Support Angle Adjustable. 18" W E0950 I Upper Extremity Support Joystick Cutout 16" W E0950 I Upper Extremity Support Joystick Cutout 18" W E0950 I Upper Extremity Support Angle Adjust - UniTrack E0950 Side mounted tray that attaches to the UniTrack Accessory Rail. Dimensions are: 19.5"W x 13"D. Can only be ordered with chairs that offer the UniTrack System. Must also select PN I I10556 Adj Removable - Tray Hardware (1 Each) I Oxygen Holder for PS or Corpus Seat E1028 Cannot be ordered with a Corpus Tubular Backrest. (I10111 or I10112). Custom charge may be applied if ordering in combination with accessories such as medical necessities bags, attendant controls, push handles, back pack clips, etc. This item is mounted to the I Ergonomic Backrest. Crutch Holder for PS or Corpus Seat Cannot be ordered with a Corpus Tubular Backrest. (I10111 or I10112). Accessories such as medical necessities bags and push handles may need to be sent as parts if ordering a crutch holder. This item is mounted to the ergonomic backrest. Page 6 of 7
7 Notes & Additional Instructions: Chair Order Policy: You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms at The order cannot be processed without the following: -A client name or code, the client s measurements, the client s weight -The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil, Inc. is not responsible for configuration or size discrepancies resulting from customer errors on the order form. -Order confirmations will be provided by Permobil summarizing the items selected. Please review this carefully. -Once the order is shipped, any changes are subject to the returns policy and may be prohibited. Order Acknowledgement: I,, am an agent of the medical equipment provider named on this order form and I have the authority to contract for the purchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete and accurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returns policy and may carry additional charges. Signed: Printed Name: Title: Date: NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if ordered with the wheelchair. Any parts ordered for service or future alterations will carry different pricing and warranty. MID PROFILE Cushion is a registered trademark of the The ROHO Group. The HCPCS codes provided are not intended to be billing or legal advice, rather our interpretation of the code definitions. Use of the codes does not ensure coverage or payment for the item. For coverage information, verify the policy of the appropriate payer. Page 7 of 7
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SHIPPING INFORMATION. Order
Size 3 Order Form MASS 2014 Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Pride Mobility Products Aust Pty Ltd 20-24 Apollo Drive Hallam VIC 3803 Ph: 03 8770 9600 Fax: 03 9703 2960 Date:
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
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)
C350 Corpus 3G R-Net. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
SpectraXTR2 HD (Modulite Flex 3 Seating or MAX System) Dealer Max User Weight 160Kg (25 stone)
Invacare Ltd Power Chair Prescription Form Pencoed Technology Park Dealer Prescription Form Pencoed CF35 5AQ LPF1U2SPECTRAXTR2HD010715DEALER Tel: +44 (0) 1656 776222 Fax: +44 (0) 1656 776220 July 2015
Positioning Components Order Form - ODJFS Only
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Positioning Components Order Form - ODJFS Only Account Number: Date: Provider
Spare Parts Catalog Online Books > Illustrated Part Catalogs > Corpus Seat (F Series and newer) > Seat Plate
Spare Parts Catalog Online Books > Illustrated Part Catalogs > Corpus Seat (F Series and newer) > Seat Plate Drawing Last update: 1/12/2015 7:32:15 AM Version: 1.0.0 1.1 1831117 SEAT FRAME PLATE, KIT CORPUS,
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
R82 Kudu - E1233. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features:
Account #: Purchase Order No.: Contact: R82 Kudu - E1233 CAD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Kudu Standard
Orderform UK / IR Valid from Version 2.1. Alex QLASS. Date:
Alex QLASS 1 / 8 0,8 Dealer: Date: Reference No.: Quantity: Delivery address: 6.948 5.559 Basic configuration Excluding VAT - 4mph/6 km/h RWD - Battery charger 8A -24 V - Armrests standard removable -
x:panda, size 1, med. back X c x:panda, size 1, med. seat 7¼" X c
Account No. Drop Ship: Date: Name P.O. Number: Address Buyer: City Marked For: State Zip E Mail: Tel. Fax Features included in standard price: Height, Depth & Angle Adjustable Back Angle Adjustable Adduction
ATP MOBILITY ASSESSMENT FORM
ATP MOBILITY ASSESSMENT FORM Name: Date: Address: City: State: Zip: DOB: Weight: Height: Gender: PLACE OF SERVICE: Assisted Living Home SNF : Physician: NPI: Address: City: State: Zip: Primary Insurance:
C500(S) Corpus 3G Lowrider R-Net
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
Standard Base Price : 2,950. Standard Features
Power Wheelchair Retail Prescription Form PRONTOM41PP010716 Tel: 01656 776222 Fax: 01656 776220 JULY 2016 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
Bora. Standard Base Price 4,100. Standard Features SEAT DEPTHS
Power Wheelchair Retail Prescription Form BORAMOD121218 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
JIVE M2 SEDEO ERGO... 5 SHROUDS... 5 CHASSIS... 5 COLOURED SHROUD ELEMENTS... 6 BACK... 37
Title - 1 - Title - 2 - Table Of Contents JIVE M2 SEDEO ERGO... 5 SHROUDS... 5 CHASSIS... 5 COLOURED SHROUD ELEMENTS... 6 BACK... 7 JAY 3 BACK... 9 SEAT... 10 DRIVE WHEEL / CASTOR WHEEL... 11 14 INCH DRIVE
Kimba. T h e K i m b a F a m i l y o f P e d i a t r i c M o b i l i t y P r o d u c t s
Kimba T h e K i m b a F a m i l y o f P e d i a t r i c M o b i l i t y P r o d u c t s Great for Kids Easy for Moms, Dads and Caregivers! Finally, a tilt-in-space mobility system that brings it all together.
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
Spare Parts Catalog Online Books > Illustrated Part Catalogs > Corpus VS > Seat plate. Drawing Last update: 1/12/2015 7:32:15 AM Version: 1.0.
Spare Parts Catalog Online Books > Illustrated Part Catalogs > Corpus VS > Seat plate Drawing Last update: 1/12/2015 7:32:15 AM Version: 1.0.0 1.1 1831117 SEAT FRAME PLATE, KIT CORPUS, CORPUS VS 1 2.1
C500(S) Corpus 3G R-Net
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
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
Specifications are subject to change without notice. 2018, Amylior Inc. (March 2018) AMYSEAT (Rev.0) Page 1 of 7
Page 1 of 7 ACCOUNT INFORMATION P.O. # or Quote: Dealer Contact Name: Email Address: Phone Number: Bill to (Name): Bill to (Location): Ship to (Name): Address: City: State: User Name or Number: User Weight:
NEMO VERTICAL Authorised client weight 100 kg + 10 kg additional load ISO-CRASH TESTED
NEMO VERTICAL 1.595 Authorised client weight 100 kg + 10 kg additional load ISO-CRASH TESTED Always finding the right position Standing function Lying function High seat width variance The new multifunctional
ALEX QLASS. Order form. T: +44 (0) F: +44 (0)
Order form ALEX QLASS T: +44 (0)8450 745 945 F: +44 (0)8450 745 946 mobilityorders@handicare.co.uk www.handicare.co.uk Valid from 1-4-2015 Version 1.0 Dealer Date Reference No. Delivery address Quantity
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
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
Orderform UK / IR Valid from Version 2.1 LUCA QLASS. Date:
LUCA QLASS 1 / 8 0,8 Dealer: Date: Reference No.: Quantity: Delivery address: 4.650 3.720 Basic configuration Excluding VAT - 4mph/6 km/h RWD - Fixed joystick bracket, right hand - PU side cushions - Drive
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
Quickie QM-7 Series. Live Without Limits. Available in Eight Group 3 and Group 4 Models:
Power Portfolio Live Without Limits The Quickie QM-7 series offers a high-performing, reliable, and stylish mid-wheel drive power solution for a client who qualifies for a Group 3 Standard (QM-710), Group
FUZE T20. Order Form - Canada Prices in Canadian 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.070118 Shipping Address * * required F r a
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. 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
For the Modulite Teen seating please select the underlined options on this form and include a completed Modulite Teen Seating form
Power Wheelchair Retail Prescription Form BORAMOD111217 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2018 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
Dealer Please check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm
EVO CEV Order form Dealer 2017 EVO Dealer: Date: Dealer reference / Client name: Order number: Anglikerstrasse 20 CH-5610 Wohlen Phone: +41 56 618 44 11 Fax: +41 56 618 44 10 e-mail: office@levo.ch configuration
The Quickie Power X series is a family of Made in Canada power wheelchairs providing reliable mobility to thousands of Canadians since 2006.
The Quickie Power X series is a family of Made in Canada power wheelchairs providing reliable mobility to thousands of Canadians since 2006. CANADIAN-MADE POWER WHEELCHAIRS NEW GENERATION X series Power
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
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
C400 VS Senior Rnet. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
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
Quantum 600 Series Group 3 Single Power & Multiple Power Order Form/ODJFS Only 300 lbs. weight capacity. Revised: December 13, 2012 Page 1 of 7
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
Setting a new standard in powered wheelchairs
Setting a new standard in powered wheelchairs The Quickie Tango is THE complete, flexible and cost-effective indoor/outdoor powered wheelchair solution. Comprehensive standard configuration includes: Powered
Product Catalog.
20080301 Product Catalog 2008 www.permobil.com Contents C300...3 Accessories, C300 chassis...4 C400...5 Accessories, C400 chassis...6 C500...7 Accessories, C500 chassis...8 Street...9 Hexior...10 X850...11
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: ( )