Serial Number: Manufacturing Date: /20
|
|
- Harriet Todd
- 5 years ago
- Views:
Transcription
1 Sunrise Medical Head Office: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: Fax: csrcanada@sunmed.com Distributor Name: Dealers Name: Contact Name: Client's Name: Address: Client's Weight: Client's Height: Postcode: Client's Disability: Country: Telephone: Notes/Coents: Purchase Order No: Delivery Address: Postcode: Contact Name: Telephone: Distributor: FOR RGK OFFICE USE ONLY A/C No: Net Value: $ Freight: $ Who Date Invoice Value: OK to Quote: $ Payment Received: OK to Confirm: $ Document No: DOC Page 1
2 Base Product Mandatory Information Information Required for Option Standard Configuration Option with No extra cost Option with Extra cost FXAXZ010 $ 6, TIGA FX A7020 XA070 Frame open design Max User Weight 125kg XW010 NC KEY FRAME MEASUREMENTS XY010 Seat width (Inside of sideguards) (Max - 460) (Min - 250) XY020 Seat length (Max - 460) (Min - 250) XY030 XY050 Seat frame additional length (Provides additional leg support & hand grip) Front frame height (Max - 550) (Min - 480) XY060 Rear frame height (Max - 550) (Min - 360) XY070 Frame length (Min XY020 + XY ) XA020 Frame ergonomic seat $ Specify length (Standard = 120) Page 2
3 XY080 Front seat taper design FRONT FRAME AND FOOTREST Front Frame Options Specify width Optimise measurements (XY ) XY100 Footrest round design (Minimum 60) Footrest Design & Measurements (Choose One) XY105 Footrest square design (Square design allows higher position) (Minimum 60) Please indicate front footrest height: Please indicate front footrest height: Individual Individual Castor Wheel Max Height Castor Wheel Max Height With XB200 Size Achievable Size Achievable 3" " 135 4" " 145 5" " 155 With XB XB200 Footrest with high level riser system (Only with XB200 $ FXAXB110) $ Footrest Individual Measurements Footrest with high level riser system (Only with FXAXB110) Rear footrest height Optimise measurements (Std = Footrest height - 20) Footrest length Optimise measurements (Std = 100) Footrest Style and Cover (Choose One) FXAXB110 Footrest fixed position welded into frame with carbon plate (Supplied with spacer kit to give 20 upward adjustment) XB160 $ Footrest grip tape fitted to any footrest cover FXAXB120 Footrest clamp-on height and angle adjustable aluminium plate Page 3
4 XC150 $ CASTOR WHEELS, FORKS & WHEEL LOCKS Castor Wheels 3" Castor wheel 3x1.4" aluminium centre frog legs (Silver hub and black urethane tyre) 4" XC060 Castor wheel 4x1.3" soft roll black XC110 $ Castor wheel 4x1" aluminium centre frog legs (Silver hub & black urethane tyre) Choose one castor option only XC130 Castor wheel 4x1.4" aluminium centre with urethane tyre frog legs $ Choose colour below (XC130 Only) : Silver hub & black tyre (Std) Black hub & black tyre Black hub & red tyre Black hub & blue tyre Red hub & black tyre Blue hub & black tyre 5" Purple hub & black tyre Gold hub & black tyre Green hub & black tyre Silver hub & blue tyre Silver hub & red tyre XC070 Castor wheel 5x1.3" soft roll black XC100 $ XC120 $ XC140 $ Castor wheel 5x1.4" aluminium centre frog legs (Silver hub & black urethane tyre) Castor Forks XC190 Castor fork low ride daily use XC210 Castor fork suspension XC220 (Standard when no option selected) $ frog legs $ Castor wheel 5" pneumatic aluminium centre Castor wheel 5x1" aluminium centre frog legs (Silver hub & black urethane tyre) Castor fork single sided uni tine frog legs Black Silver Black Silver Black Silver XY330 Castor pin width (XY010 plus 70) Castor Pin Width Scissor Wheel Lock Options Other XD020 Wheel locks underseat scissor XD050 Wheel locks push to lock XD040 Wheel locks scissor levers drilled $ XD030 Wheel locks compact scissor $ XD035 Wheel locks compact scissor with lightweight fixing $ (Only with fixed centre of gravity) XD010 Wheel locks omit Page 4
5 Sideguard Aluminium Options SIDEGUARDS AND ARMRESTS Sideguard with Fender Aluminium Options XE080 Sideguards lift out aluminium XE090 $ $ FXAXE130 Sideguards fold flat aluminium FXAXE140 $ $ Carbon Fibre Options Sideguards lift out aluminium with fender Sideguards fold flat aluminium with fender Carbon Fibre Options XE100 Sideguards lift out carbon fibre XE110 Sideguards lift out carbon fibre with fender $ $ FXAXE150 Sideguards fold flat carbon fibre FXAXE160 Sideguards fold flat carbon fibre with fender $ $ XE120 $ FXAXE170 $ ABS Plastic Options Sideguards lift out ABS plastic Sideguards fold flat ABS plastic Sideguard Measurements Optimised measurements Fender sideguard height above tyre (Min = 10) Choose optimised or individual measurements XF010 $ Armrest fixed height, lift out with plastic sideguard (Indicate height) XF020 Armrest fixed height, lift out with aluminium sideguard $ (Indicate height) Height (Top of seatrail to top of armrest) Sideguard Measurements Optimised measurements Sideguard 25 above tyre (Follow tyre - Std if not indicated) Sideguard individual above tyre (Follow tyre) Sideguard length Armrest Options Sideguard level with tyre (Follow tyre) Individual measurements Choose optimised or individual measurements Optimise (10 above tyre) Individual measurements Fender sideguard to centre of tyre (Standard if no option selected) Fender sideguard to outside of tyre Sideguard height Page 5
6 Page 5
7 BACKREST Backrest Height - Fixed or Adjustable (Choose One) Backrest height fixed (Maximum 400) Specify height XY245 $ Backrest height adjustable (Maximum 400) (Upward range 50) Indicate lowest height Backrest Design - Fixed or Folding (Choose One) FXAXG060 Backrest folding with Q Lock Ergonomics - Rearward Positioning (Choose One) XY360 Backrest angle XG100 Backrest ergonomic $ Vertical height (Min 250) Individual (Max -7/+7 Deg) Deg Rearward position Ergonomics - Lateral Positioning (Choose One) XG110 Backrest inward taper XG120 $ (Above sideguards) $ Backrest outward flare (Above sideguards) Width Width Push handle Options XG070 $ XG080 $ XG085 $ Backrest with screw in push handles (N/A with XY245) Backrest with flip down push handles (N/A with XY245) Backrest with flip down push handles height adjustable (N/A with XY245) Page 6
8 Adjustable Centre of Gravity CAMBER BAR Fixed Centre of Gravity Centre of gravity - Choose one XH110 XH120 Camber bar adjustable position square back frame (25-150) (Max seat width 500) Centre of gravity adjustable round back frame (60-150) Centre of gravity - Choose one FXAXH090 $ Camber bar fixed position integrated into frame V design (25-125) Specify Camber Angle Specify Camber Angle XY390 Camber angle XY390 Camber angle Camber Bar Options Camber Bar Options XH030 Suspension camber bar XH040 $ frog legs $ Handbike camber bar fixed welded XH040 $ Handbike camber bar fixed welded Camber angle (Handbike camber bar) 0 5 Castor height from floor for handbike fitting (Standard 30 if not indicated) Camber angle (Handbike camber bar) 0 5 Castor height from floor for handbike fitting (Standard 30 if not indicated) Anti-Tip Options XJ010 Anti tip swingaway left side (Only with square back XJ020 $ frame. Not with XH040) $ Anti tip swingaway right side (Only with square back frame. Not with XH040) Page 7
9 XY420 XY460 REAR WHEELS Wheel Size Wheel size 24" XY430 Wheel size 25" Rear wheel gap Wheel Gap XY440 Wheel size 26" XK010 Spinergy Colour Options Wheel Sun Fusion 16 spoke daily use XK050 Wheel Spinergy LX 12 spoke daily use $ (select colour below) XK210 Wheel Topolino carbon core with red accents $ 1, (24", 25" only) Wheel Options (Choose one) XK320 $ XK060 $ XK070 $ Wheel Spinergy XLX 12 spoke cross spoked daily (select colour below) Black spoke / Silver hub White spoke / Black Hub XK180 Spinergy spoke colour custom $ (Specify below) Red spoke / Black hub Blue spoke / Black hub Colour inside Yellow spoke / Black hub Green spoke / Black hub Colour outside Wheel Spinergy SPOX 18 spoke daily (select colour below) Wheel Spinergy BLXL 18 blade spoke daily, rivnut handrim mounting (select colour below - Note: Black hub only) Pink spoke / Black hub Orange spoke / black hub Note: Supply picture for custom designs XK190 Spinergy black hub with black spokes XK200 Spinergy silver hub with coloured spokes $ $ XK040 Wheel omit / supply without - $ (Specify wheel type / size / tyre) Handrim set narrow (Standard if no option selected) Handrim set wide XL010 Handrim aluminium hard anodised 6 tab XL040 Handrim titanium 6 tab (Standard if No option selected) $ XL030 Handrim surge LT 6 tab XL050 Handrim stainless steel 6 tab $ $ XL020 Handrim tetra grip 6 tab XL090 Handrim remove excess mounting tab $ $ (Recoended when XY460 is 20 or XL100 Handrim para grip 6 tab less) (Narrow set only) $ Tyre Options XM010 Kenda Tyre High Pressure Grey Blue Red (Standard if no option XM130 Kenda black selected) $ XM020 Tyre Schwalbe Marathon Plus XM060 Tyre Schwalbe One (24",25" only) $ $ XM040 Tyre Shox solid airless black only XM050 Tyre Kenda K885 mountain bike tyre $ (24",25" only) $ (24",25" only) Inner Tube Valve Options XY500 Schraeder inner tube valve (Standard if no option selected) Handrim Position Handrim Options XY490 Presta inner tube valve Wheel Accessories XK220 Wheel titanium quick release axle pin (pair) XK300 $ (N/A with XK010 & XK070) $ XK240 Wheel quad release axle nut (pair) $ XK310 XK250 Wheel transparent polycarbonate spokeguard (pair) $ $ Offroad wheel set 22" rim with handrim, MTB tyre and axle pins (Replaces 24" wheel with XM010) Offroad wheel set 24" rim with handrim, MTB tyre and axle pins (Replaces 25" wheel with XM010) Page 8
10 XN010 Specify Code Frame Finish frame powder coated (Includes H-frame) FRAME FINISH OPTIONS XN150 Specify Code Components Finish components powder coated (Camber bar & sideguards) (Standard black if not Indicated) FXAXN030 Finish frame brushed aluminium XN160 Finish components brushed $ $ (Camber bar & sideguards) FXAXN050 Finish frame polished aluminium XN170 Finish components polished $ $ (Camber bar & sideguards) Accent Colour (Choose One) Finish accent colour black Finish accent colour red Finish accent colour silver Finish accent colour blue Finish accent colour purple UPHOLSTERY Seat Upholstery XP040 Upholstery seat sling adjustable tension with straps (Standard if not indicated) XR050 $ Accessory carbon fibre seat plate in lieu of seat upholstery XP050 XP060 $ XP070 $ Upholstery backrest Airtech adjustable tension with straps (Standard if not indicated) Upholstery backrest upgrade to full leather Leather colour black Leather colour red Leather colour grey (Standard if not indicated) Upholstery upgrade to leather corners on side wings - (N/A with XG080) Backrest Upholstery Backrest Upholstery Leather Options Leather colour black (Standard if not indicated) Silver (Standard if not indicated) Leather colour red Backrest Upholstery Stitching Options Black Leather colour grey Blue Red Light blue Purple Backrest Upholstery Logo Options Silver (Standard if not Black Blue Red Light blue Purple XP110 Backrest Accessories Upholstery backrest with zip fasten pocket XP170 Upholstery with individual embroidery $ $ (please provide.jpeg file and positioning) Page 9
11 CUSHION XP080 $ Upholstery cushion foam with nylon cover Cushion foam soft Cushion foam medium Cushion foam hard (CMS040) (CMS050) (9lb recon) Cushion thickness 50 Cushion thickness 75 Cushion thickness 100 XP090 $ XP100 $ Upholstery cushion cover upgrade to Air Lite Upholstery cushion cover upgrade to leather Leather colour black Leather colour red Leather colour grey FRAME OPTIONS XR080 $ Accessory front wheel assembly Frontwheel serial number (Office use only) XR010 $ Accessory seat pouch velcro attach (Black standard) ACCESSORIES XR100 $ XR090 XS060 Accessory FX carry bag Accessory toolkit Accessory calf strap Page 10
12 NOTES Page 11
Serial Number: Manufacturing Date: /20
Sunrise Medical Head Office: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: +1.800.263.3390 Fax:+1.800.561.5834 csrcanada@sunmed.com www.sunrise.ca Distributor Name: Dealers Name: Contact
More informationRGK Tiga Sub4. July Serial Number: Manufacturing Date:
Manufacturing Date: Sunrise Medical Head O ce: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: +1.800.263.3390 Fax:+1.800.561.5834 E-Mail: cscanada@sunmed.com www.sunrisemedical.ca RGK
More informationSerial Number: Manufacturing Date: /20
49 Bespoke Inc. 51 Caldari Road, Units 6-7B Concord, ON L4K 4G3, Canada Telephone: +1.866.827.4548 Fax:+1.877.731.7745 49@49Bespoke.com www.49bespoke.com Distributor Name: Dealers Name: Contact Name: Client's
More informationSerial Number: Manufacturing Date: /20
RGK Head Office: Unit 8 A,B/C Ring Road, Zone 2 Burntwood Business Park, Burntwood Staffordshire. WS7 3JQ. UK Telephone:+44(0)1543 670077 Fax:+44(0)1543 670088 info@rgklife.com www.rgklife.com Customer
More informationSling 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
More informationPlease make your selection with a cross in the box Standard feature Free of Charge
Manual Wheelchair Retail Prescription Form Champion161116 Tel: 01656776222 Fax: 01656776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk JANUARY 2017 Account No : Built in
More informationSEATING CHOICE TITANIUM FRONT FRAME
Manual Wheelchair Retail Prescription Form Champion140618 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk July 2018 Account No : Contact
More informationMEDmobility 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
More informationFrame. 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
More informationCondor 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
More informationThis wheelchair has a weight limit of 80kg
90355 ATTENTION This wheelchair has a weight limit of 80kg If you require a suspension wheelchair and you currently weigh over 80kgs, please consider the Melrose Shockwave. If you need a wheelchair without
More informationKüschall Ultra Light RETAIL Maximum user weight 130kg (20.5 Stone)
Manual Wheelchair Retail Prescription Form UltraLight061216 Tel: 01656776222 Fax: 01656776220 Email: ordersuk@invacare.com JANUARY 2017 Online spares available at: www.invacare.co.uk Account No : Built
More informationMASS 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
More informationStallion 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
More informationMASS 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
More informationk-series Aluminium Standard Features
Manual Wheelchair Retail Prescription Form KSeries200618 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk July 2018 Customer Ref: Account
More informationchampion Standard Base Price 1,875 Standard Features
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed. CF35 5AQ LPF1U2CHAMPION290514D Tel: 01656 776222 Fax: 01656 776220 LPF0015Z email: ordersuk@invacare.com January
More informationchampion carbon Customer weight = Kg Code X Description Dealer SEATING CHOICE DDF0204 küschall Champion Carbon 85 Frame Angle
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed. CF35 5AQ LPF1U2CHAMPION211114D Tel: 01656 776222 Fax: 01656 776220 LPF0015Z email: ordersuk@invacare.com January
More informationCondor 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
More informationOrder Date : carbon. Tension adjustable seat, option DDA0611 is not possible with seat width 320mm
Manual Wheelchair Retail Prescription Form KSeriesCarbon061218 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk January 2019 Customer Ref:
More informationORDER 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:
More informationSEAT 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
More informationRETAIL 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
More informationMax. 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:
More informationq 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
More informationORDER 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:
More informationORDER 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:
More information4.2 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
More informationTown: 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:
More informationKüschall Champion DEALER Maximum user weight 120kg (19 Stone)
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription form Pencoed. CF35 5AQ LPF1U2CHAMPION011113D Tel: 01656 776222 Fax: 01656 776220 LPF0015X email: ordersuk@invacare.com January
More informationnoir 2.0 Order Form NONO Carbon fibre frame made-to-measure. English Company stamp Date User name Responsible Seat depth (PS)
NONO Date User name Order Form Company stamp Rigid frame wheelchair Responsible Carbon fibre frame made-to-measure. Front height 35 37,5 Frame Angle 40 42,5 Backrest rake adjustable from -4 to +16 85 90
More informationOrder Form. English Company stamp. Version mudguard (AVAILABLE ONLY WITH REAR WHEELS 24'') Version straight sideguard
NONO Date User name Company stamp Rigid frame wheelchair Responsible Wheelchair measures Seat width (LS) 33 36 39 42 45 48 The seat width is measured from the outer sides of the frame, while the distance
More informationKüschall K Series DEALER Maximum user weight 120kg ( 19 Stone )
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed LPF1U2KSERIES021213D CF35 5AQ LPF0019X Tel: 01656 776222 Fax: 01656 776220 January 2014 email: ordersuk@invacare.com
More informationAPEX 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:*
More informationTiLite. 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
More informationAPEX 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:*
More informationAdditional Front Wheel Options Not Shown FW1 3 x.75 Micro-Caster FW14 4 x.75 Plastic Wheel w/poly Tire FW3 4 x.75 Light-Up Micro-Caster
front wheels FW2 3 x.75 Light-Up Micro-Caster FW23 3 x1.5 Billet Aluminum Micro Caster w/soft Roll Tire FW19 4 x.75 Performance 5 Spoke Billet Aluminum Wheel w/poly Tire - Silver Hub OR Black Hub FW20
More informationVoyager Evo. Rigid-frame active wheelchair. Standard equipment. Canada: Fax: Order Form and Price List
Voyager Evo Rigid-frame active wheelchair Order Form and Price List Canada: 800.665.3327 Fax: 800.463.3659 www.ottobock.ca Provide estimate only Account Information Order Article number: 480A76=00000_K
More information1,795. 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:
More informationORDER 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:
More informationYOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP.
ROGUE XP YOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP. FOCUS ON PUSHING YOUR LIMITS. NOT YOUR CHAIR. Rogue XP is the ultimate performance chair; encouraging you to embrace your
More informationAuftrags-Nr.: Order no.: ... Date Signature. MA 110 Standard
Zenit Active Wheelchair Auftrags-Nr.: Order no.: Zenit Active wheelchair Article number: 480F160=1_AA01_C Provide estimate only Order Billing address/customer number Delivery address Ottobock Zenit_647F557=EN-01-1611
More informationKüschall Champion DEALER Maximum user weight 120kg (19 Stone)
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription form Pencoed. CF35 5AQ LPF1U2CHAMPION240513D Tel: 01656 776222 Fax: 01656 776220 LPF0015W email: ordersuk@invacare.com July 2013
More informationZippie 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:
More informationQuickie Q7 Adjustable March 2014
Quickie Q7 Adjustable March 2014 EIR4 Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer
More informationOrder Form. English Company stamp
NONO Date User name Company stamp Rigid frame wheelchair Responsible Wheelchair measures Seat width (LS) 24 27 30 33 36 Seat depth (PS) 27,5 30 32,5 35 37,5 40 Seat depth can be increased by 2,5 or 5 cm.
More informationQuickie 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
More informationThis 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:
More information4.6. 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:*
More informationInvoice address: same as company address. Invoice address: other (see below) Cust. no.: Name: Street: Postcode, city: Phone: Fax: Contact:
Im Hofstätt 11 D- 72359 Dotternhausen Tel +49 (0)7427 9480-0 Fax +49 (0)7427 9480-7025 e-mail info@proactiv-gmbh.de www.proactiv-gmbh.de Quotation date: Order date: according to GTC PRO ACTIV GmbH TRAVELER
More informationManual Wheelchair Pencoed Technology Park. DEALER Prescription form Pencoed. CF35 5AQ. LPF1U2ULTRALIGHT211113D Tel: Fax:
Invacare Ltd Manual Wheelchair Pencoed Technology Park DEALER Prescription form Pencoed. CF35 5AQ LPF1U2ULTRALIGHT211113D Tel: 01656 776222 Fax: 01656 776220 LPF0020X email: ordersuk@invacare.com January
More informationSPEEDY 4all "Classicline"
Im Hofstätt 11 D- 72359 Dotternhausen Tel +49 (0)7427 9480-0 Fax +49 (0)7427 9480-7025 e-mail info@proactiv-gmbh.de www.proactiv-gmbh.de Quotation date: Order date: according to GTC PRO ACTIV GmbH SPEEDY
More informationOrder Date : k-series. titanium. Please make your selection with a cross in the box Standard feature Free of Charge
Manual Wheelchair Retail Prescription Form KSeriesTitanium040516 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com July 2016 Online spares available at: www.invacare.co.uk Customer Ref:
More informationMODEL ZX1 CHARACTERISTICS, POTENCY AND BENEFITS
MODEL 1.360 ZX1 CHARACTERISTICS, POTENCY AND BENEFITS ADAPTIV-ROLLSTÜHLE ECONOMICAL Continuous provision with adjustment possibilities, reduces additional follow-up costs Wide range of standard options
More informationQuickie 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
More informationWheelchair Portfolio. Active wheelchair
Wheelchair Portfolio Active wheelchair K-Series Content Frame...2 Backrest...3 Footrest...8 Side guards... 11 Cushions and options... 13 Colours... 14 Front wheels... 16 Rear wheels... 17 Brakes... 25
More informationTransformer. Rev C. Aug 15, 2010 Page 1 of 8
Transformer Rev C. Aug 15, 010 Page 1 of 8 www.topendwheelchair.com Rev C. Aug 15, 010 Page of 8 www.topendwheelchair.com ITEM PART NUMBER PER CHAIR DESCRIPTION 1 1116570 1 Upper Seat Frame, specs required
More informationSTD +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:*
More information4.6. 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:*
More informationRESIST CONFORMITY. GO ROGUE.
ROGUE RESIST CONFORMITY. GO ROGUE. IT IS IN THE SOUL OF THE ROGUE, THE WAY IT STANDS OUT, ITS DEFIANCE OF CONVENTION, ITS INDEPENDENCE THAT SEPARATES IT FROM ALL OTHERS. ROGUE. AN ULTRA RESPONSIVE RIDE.
More informationOrder Date: SHIP TO Name: Address: : City: Phone: PRICEE
DEALER Dealer: C O L O U R ECL IPS E Account: P.O.#: Ordered By: Address: City: Phone: Email: Customer Name: Customer Weight: CHAIR INFORMATION ECLIPSE K0005 Adjustable FSH-RSH Capacity 250Lbs NOTE Max.
More informationNOT 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
More informationMASS 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
More informationBUDDY "Classicline" Active easy running wheelchair
Im Hofstätt 11 D- 72359 Dotternhausen Tel +49 (0)7427 9480-0 Fax +49 (0)7427 9480-7025 e-mail info@proactiv-gmbh.de www.proactiv-gmbh.de Quotation date: Order date: according to GTC PRO ACTIV GmbH BUDDY
More information4.2. 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
More informationCustom 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
More informationCOST EFFECTIVENESS THERAPEUTIC BENEFITS APPLICATIONS. the optimal smoothness and lightweight design facilitate the independence of the user
XSTAR 1.160 Individual setting made easy Elegant frame design Smooth pressure brake Newly designed steering head socket A strong character COST EFFECTIVENESS THERAPEUTIC BENEFITS APPLICATIONS for long-term
More informationVELOCE 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:*
More informationQuickie 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:
More information3 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.
More informationIT S NOT IMAGINARY. IT S REALITY. BRINGING YOU LITTLE WAVE.
LITTLE WAVE IT S NOT IMAGINARY. IT S REALITY. BRINGING YOU LITTLE WAVE. IMAGINE... A wheelchair that has the ability to move easily within its environment; where the wheels are in the perfect spot so that
More informationParts Catalog Issued: Apr 11, Crossfire T7A. Adjustable Rigid Wheelchair
Parts Catalog Issued: Apr, 08 Crossfire T7A Adjustable Rigid Wheelchair Parts Catalog Usage Guide The information contained in this document is subject to change without notice. This catalog contains service
More informationTop End Crossfire T7A Ultra Lightweight AADL Customers Only Active Performance Adjustable Rigid Wheelchair AADL # W149
Top End Crossfire T7A Ultra Lightweight AADL Customers Only Active Performance Adjustable Rigid Wheelchair AADL # W149 Suggested Canadian Price List Effective October 1 st, 2018 For accuracy of ordering,
More information4.1 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
More informationEtac Cross 5 and Cross 5 XL
Etac Cross 5 and Cross 5 XL The new generation wheelchair with the optimum prerequisites for delivering comfort and excellent manoeuvrability. Etac Cross 5 when every little detail makes a big difference
More informationBEARINGS 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....
More informationUNMATCHED PERFORMANCE. THE PROFESSIONALS BEST CHOICE IN FOLDING ULTRA- LIGHTWEIGHT ABILITY.
CATALYST UNMATCHED PERFORMANCE. THE PROFESSIONALS BEST CHOICE IN FOLDING ULTRA- LIGHTWEIGHT ABILITY. INNOVATIVE AND PATENTED FRAME DESIGN Catalyst frames are constructed from 7000 series aluminum. A stronger
More informationThe lightest folding wheelchair in the world - now with swing away legrests!
The lightest folding wheelchair in the world - now with swing away legrests! The lightest FOLDING wheelchair in the world, now with swing-away legrests. Quickie has combined the latest ultra-light, hydroformed
More informationBlack -01 Moss green -95 Yellow -99. Heather purple -97. Indicate height. Indicate height. Indicate angle. Indicate height: cm. Indicate height: cm
Cross 5 XL Prescription form 75188K 017-05-08 Reference: Name: Tel: Date: version is marked with The measurements given can vary ±% Short frame Seat width (cm) Seat depth 36-4 (-49*)cm Measured from back
More informationDealer 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
More informationAccount 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
More informationPlease check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm
EVO AE 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
More informationOctober 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:
More informationKüschall K - Junior INVACARE IRELAND LTD Maximum user weight 60kg ( 9.5 Stone )
Invacare Ireland Ltd Manual Wheelchair Unit 5, Seatown Business Campus Ireland Prescription form Seatown Road LPF1U2K-Junior010712IRE Swords, Co Dublin LPF0618U Tel: (00353) 1 8107084 Fax: (00353) 1 8107085
More informationParts Catalog Issued: Apr 11, Crossfire T6A. Wheelchair
Parts Catalog Issued: Apr, 208 Crossfire T6A Wheelchair Parts Catalog Usage Guide The information contained in this document is subject to change without notice. This catalog contains service parts for.
More information4.8. 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:*
More informationAccount 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
More informationTilt 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
More informationQuickie 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:
More information4.8. 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:*
More informationQuickie 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
More information4.8. 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.
More information2241 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
More informationStandard 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
More informationOrder form LEVO LAE 2011/1
Seat height 48 Seat height 51 Seat height 54 Seat height 57 Order form LEVO LAE 2011/1 Please answer the following questions exactly and consider the indications.the exact measurement within the pictograms
More informationInvacare 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
More informationC2 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.
More informationq 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
More informationInvacare 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:
More informationHelio 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:*
More information