RGK Tiga Sub4. July Serial Number: Manufacturing Date:
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1 Manufacturing Date: Sunrise Medical Head O ce: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: Fax: cscanada@sunmed.com RGK Tiga Sub4 July 2018 Distributor Name: Contact Name: Dealers Name: Client's Name: Address: Client's Weight: Postal Code: Client's Height: Country: Client's Disability: Telephone: Notes/Coents: Purchase Order No: Delivery Address: Postal Code: Contact Name: Telephone: FOR RGK OFFICE USE ONLY Distributor: Net Value: $ A/C No: Freight: $ Who Date Invoice Value: $ OK to Quote: Payment Received: $ OK to Con rm: Document No: DOC Page 1 of 9
2 Base product Mandatory informa on Informa on required for op on Standard con gura on Op on with no extra cost Op on with extra cost SBAXZ010 $ 7, TIGA Sub4 A7020 XA070 Frame open design Max User Weight 110kg XW010 NC KEY FRAME MEASUREMENTS XY010 Seat width (Inside of sideguards) (Max - 440) (Min - 250) XY020 Seat length (Max - 440) (Min - 250) XY030 Seat frame addi onal length (Provides additional leg support & hand grip) (Max total seat) XY050 Front frame height (Max - 520) (Min - 380) XY060 Rear frame height (Max - 500) (Min - 360) XY070 Frame length (Min = XY020 + XY ) (Max - 625) XA020 $ Frame ergonomic seat Specify length (Standard = 120) Page 2 of 9
3 XY080 Front seat taper design FRONT FRAME AND FOOTREST Front Frame Op ons Footrest width Specify width Specify width (Optional, to provide additional leg support / positioning) (When combined with XY080, dimensions must be smaller) 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 Size 4" Max Height Achievable 110 Castor Wheel Size 4" Max Height Achievable 130 Rear footrest height Footrest Individual Measurements O mize measurements (Std = Footrest height - 20) Footrest length Maximum length 140 XB010 XB045 O mize measurements (Std = 100) Footrest height adjustable lightweight tubular aluminium Footrest cover lightweight carbon Footrest Style Footrest Cover Page 3 of 9
4 CASTOR WHEELS, FORKS & WHEEL LOCKS Castor Wheels XC135 Castor wheel 4x1.25" aluminium centre with urethane re frog legs Choose colour below: Silver hub & black re (Std) Black hub & black re Purple hub & black re Green hub & black re Red hub & black re Blue hub & black re XC190 Castor fork low ride daily use Castor Forks Black Silver XY330 Castor pin width Op ze measurements (Minimum width for clear castor rotation and maximum wheelbase length) Castor Pin Width Wheel Lock ns SBAXD036 Wheel locks compact scissor with XD010 lightweight xing Wheel locks omit Sideguard Carbon Fibre ns SIDEGUARDS Sideguard with Fender Carbon Fibre ns XE055 Sideguards screw on lightweight carbon re XE065 Sideguards screw on lightweight carbon bre with fender Sideguard Measurements ized measurements Sideguard Measurements ized measurements Sideguard individual above re (Follow tire) max 25 Sideguard level with re (Follow tire) Fender sideguard height above re (Min = 10) Op ze 10 above re (Std if not indicated) Fender sideguard to centre of re Page 4 of 9
5 Backrest Height - Fixed BACKREST Backrest Design - Fixed Backrest height xed Specify height XG010 Backrest xed (Non-folding) XY360 Backrest angle Ergonomics - Rearward Posi oning (Choose One) XG100 Backrest ergonomic $ Ver cal height (Min 250) Individual Deg (Max -10/+20 Deg) Rearward posi on Ergonomics - Lateral Posi oning (Choose One) XG110 Backrest inward taper XG120 $ (Above sideguards) $ Backrest outward are (Above sideguards) Width Width Specify Camber Angle CAMBER BAR Fixed Centre of Gravity XY390 Camber angle SBAXH100 Camber bar xed posi on welded into frame single post (25-125) FRAME FINISH OPTIONS Frame and Footrest SBAXN030 Finish frame brushed SBAXN050 Finish frame polished Accent Colour (Choose One) Finish accent colour black Finish accent colour silver Finish accent colour red Finish accent colour blue Finish accent colour purple XP045 XP035 Upholstery seat sling Sub4 adjustable tension Upholstery backrest Sub4 adjustable tension UPHOLSTERY Seat Upholstery Backrest Upholstery Silver (Standard if not indicated) Red Backrest Upholstery S tching Op ons Black Light blue Other Upholstery Blue Purple XS065 Accessory lightweight Calf Strap Page 5 of 9
6 REAR WHEELS (* non certi Wheel Size d weight options) XY420 Wheel size 24" XY430 Wheel size 25" Wheel Gap XY460 Rear wheel gap XK225 Wheel tanium quick release axle pin (pair) Wheel Op ons Spinergy Colour Options Black spoke / Black hub White spoke / Black Hub XK180 Spinergy spoke colour custom $ (Specify below) Red spoke / Black hub Blue spoke / Black hub Colour inside XK075 Yellow spoke / Black hub Green spoke / Black hub Colour outside Wheel Spinergy BLXL 18 blade spoke daily, rivnut handrim moun ng (select colour below - Note: Black hub only) Pink spoke / Black hub Orange spoke / black hub Note: Supply picture for custom designs XK040 Wheel omit / supply without $ (212.00) (Specify wheel type / size / tyre) Handrim set narrow (Standard if no option selected) Handrim Posi on Handrim Op ons Handrim set wide XL010 Handrim aluminium hard anodized 6 tab (Lightest Op on) XL040 Handrim tanium 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 moun ng tab $ $ (Recoended when XY460 is 20 or XL100 Handrim para grip 6 tab less) (Narrow set only) $ Tire Op ons XM060 $ XM010 XM130 $ XM020 $ XM040 $ Tire Schwalbe One (Lightest op on) Kenda Tire High Pressure Kenda black Tire Schwalbe Marathon Plus Tire Shox solid airless black only (24",25" only) Grey (Standard if no option selected) XM050 $ Inner Tube Valve Op ons Blue Red Tire Kenda K885 mountain bike re (24",25" only) XY500 Schraeder inner tube valve (Standard if no option selected) XY490 Presta inner tube valve * Indicates items that are not part of the cer d weight of the Tiga Sub4 Page 6 of 9
7 CUSHION (** non certi ed weight options) XP080 $ Upholstery cushion foam with nylon cover Cushion foam so Cushion foam medium Cushion foam hard (CMS040) (CMS050) (9 lbs. 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 (** non certi ed weight options) XR060 Accessory welded calf strap moun ng loops $ (To locate calf strap on front frame) XR080 $ Accessory frontwheel assembly (Only with XB010, TGAXB080, XB150) Frontwheel serial number (O ce use only) ACCESSORIES (** non certi ed weight options) XP120 $ Upholstery frame protectors neoprene zip fasten with TIGA logo (Nylon with velcro fasten with XR060) XR010 $ Accessory seat pouch velcro a ach (Black) XR020 Accessory large underseat storage bag (Black) $ XR090 Accessory toolkit ** indicates op ons that, when chosen, will not enable RGK to guarantee a Sub4kg product weight Page 7 of 9
8 XB200 Footrest with high level riser system Please indicate front footrest height: $ XC150 $ Castor wheel 3x1.4" aluminium centre frog legs (Silver hub and black urethane tire) OTHER (** non certi ed weight options) Footrest Castor wheels 3 and 5" XC070 Castor wheel 5x1.3" so roll black XC100 $ XC120 $ XC140 $ Castor wheel 5" pneuma c aluminium centre Castor wheel 5x1" aluminium centre frog legs (Silver hub & black urethane tire) Castor wheel 5x1.4" aluminium centre frog legs (Silver hub & black urethane tire) Wheel Lock Op ons XD020 Wheel locks underseat scissor XD050 Wheel locks push to lock Sideguards XE030 Sideguards screw on aluminium, indicate size on page 4 $ SBAXG020 $ XG070 $ Backrest Op ons Backrest folding with 2 posi on snap lock and angle adjust Push handle Op ons Backrest with screw in push handles (N/A XG080 with XY245) $ Backrest with p down push handles An -Tip Op ons XJ100 $ XP040 An p single sport Upholstery seat sling adjustable tension with straps Seat Upholstery XR050 $ Accessory carbon bre seat plate in lieu of seat upholstery Backrest Upholstery XP050 Upholstery backrest Airtech adjustable tension with straps XP070 $ Upholstery upgrade to leather corners on side wings - (N/A with XG080) Leather colour black (Standard if not Indicated) Silver (Standard if not indicated) Backrest Upholstery Leather Op ons (only with XP050) Leather colour red Backrest Upholstery S tching Op ons (only with XP050) Black Leather colour grey Blue Red Light blue Purple Backrest Upholstery Logo Op ons (only with XP050) Silver Black (Standard if not indicated) Blue Red Light blue Purple Backrest Accessories (only with XP050) XP110 Upholstery backrest with zip fasten pocket XP170 Upholstery with individual embroidery $ $ (Please provide.jpeg e and positioning) ** indicates op ons that, when chosen, will not enable RGK to guarantee a Sub4kg product weight Page 8 of 9
9 NOTES Page 9 of 9
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
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
Serial 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
Serial 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
Sling Position. Push Handle. q Omit Push Handles N/C q Standard Push Handles 53 q Fold Down Push Handles 80 q Bolt-On Push Handles 109
Effective 05/07/2014 Company: Account Number: Date: q Quote q PO Number: RTS: Marked For: q Rogue XP 1825 Rogue Width Grow-able Frame. 275 lb weight capacity. Maximum initial : 16. q Rogue 1495 Rogue Standard
MEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:
Canada MEDmobility 5711- Calgary Trail NW Edmonton AB T6H 2K1 P: 780-437-3300 F: 780-430-9381 www.medmobility.ca Company: Account Number: Date: Quote PO Number: RTS: AADL #W154 Effective 10/01/2017 Ship
Frame. Backrest. Seat Depth. Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time free growth kit. 165 lb weight capacity.
Canada Patent Pending AADL #W157 Effective 10/01/2017 Company: Ship To: Account Number: Date: Quote PO Number: RTS: Marked For: Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time
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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
ORDER FORM Ver.9.0 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
C O L O U R S C H U M P - G ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
Please 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
SEATING CHOICE TITANIUM FRONT FRAME
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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
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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
ORDER FORM Ver.9.0 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
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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
APEX 4.7. FRONT Seat-to-floor height ORDER FORM - USA. Height available +- 1/4" Caster sizes. 3" Caster 14" to 21" Specify desired height:
2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.7 APEX ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
RETAIL Max user weight: 100kg - seat widths 12" & 13" Max user weight: 130kg -seat widths 14" -16"
Manual Wheelchair Retail Prescription Form ACTION515112017 Tel: 01656 776222 Fax: 01656 776220 JAN 2018 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer Ref: Contact
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ORDER FORM Ver.9.0 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
C O L O U R S S PA Z Z - G ORDER FORM Ver.9.0 Rev-072513 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
Town: Postal code: Town: Postal code: CLIENT MEASUREMENTS. Seat Width in cm 38 cm 40 cm 42 cm 44 cm 46 cm. 40 cm
Front Castor Seat Depth in cm Deliver to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: E-Mail: E-Mail: Tel: Fax: Tel: Fax: Order date: Purchase order: Number required:
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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:*
1,795. Base Price. Part no.: CLIENT MEASUREMENTS. Town: Postal code: Town: Postal code: Tel: Fax: Tel: Fax: Purchase order:
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This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.
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ORDER FORM Ver.6 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:
C O L O U R S ZEPHYR EVERY DAY ORDER FORM Ver.6 Rev-091211 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
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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
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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
Quickie GTX Swing-Away FSS NET ORDER FORM/PRICE LIST (SIN F-1)
Account No: Drop Ship/Ship To: Date: Name: P.O. #: Address: Buyer: City: State: Marked For: Zip Code: Phone Number: Seat Depth (Continued) 163SD10 17" NC 163SD11 18" NC 163SD12 19" 1 NC Frame Style 163SD13
The lightest folding wheelchair in the world - now with swing away legrests!
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NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM.
LITTLE WAVE NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM. EVOLVING AND GROWING WITH YOUR CHILD Seat height, width, depth, CG, caster wing position, seat upholstery, seat pans the most built in adjustment
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
Please 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
Top 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,
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
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
COST 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
3 A7WC10 E-Motion adaptor Kit (2 adaptors)
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.7 Helio A7 ORDER FORM - INTERNATIONAL P.O.
Invoice 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
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
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
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
SPEEDY 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
lightweight-rigid for handling and performance
efficient f ff driving i f c itechnology i e cn t i de r ni v 02 driving technology Helium encompasses the latest in cycle and automotive racing technologies for the 2010 decade. Designed and engineered
HELIUM NEXT GENERATION STYLE
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RESIST CONFORMITY. GO ROGUE.
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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....
4.8. A6MA085 Italian Manual. 3" caster 4" caster. 8" caster Stem bolt Length. + 2,54 cm 1" + 5,08cm 2" STD. 36,8cm 14,5" 34,3cm 13,5" 39,4cm 15,5"
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio A6 ORDER FORM - INTERNATIONAL P.O.
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
Helio A6 ORDER FORM - CANADA
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.7 Helio A6 ORDER FORM - CANADA P.O. number:*
Order 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.
Black -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
The lightest folding wheelchair in the world
The lightest folding wheelchair in the world Minimalistic oval frame combined with an innovative, patented flat cross brace design gives the Quickie Xenon an impressive stylish and active look. The lightest
Helio A6 ORDER FORM - CANADA
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio A6 ORDER FORM - CANADA P.O. number:*
Order 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:
Parts 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
4.8. Name: K0005. Stem bolt Length /2 15 1/2 16 1/ /2 15 1/2 16 1/ /2 16 1/2 17 1/2
2915 Ogletown RD # 2270 Newark, DE 19713 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
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:
C2 FRONT Seat-to-floor Height - Please select your choice. Custom Technologies Limited. 40 Raywood Crescent TAUPO. New Zealand
4.7 160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com Helio C2 ORDER FORM - INTERNATIONAL P.O.
4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required KDMA063 English Manual (STD) Manuel Français
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 P.O. number:* Date: Ship to:* Company Name:*
MODEL 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
UNMATCHED 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
4.2. Ship to: Vendor: Name: Date: Address: Ordered by: Phone:
519, J-Oswald Forest, suite 101 Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.450 588-6555 1 866 650-6555 F.450 588-0200 orders@motioncomposites.com www.motioncomposites.com 4.2 MOVE ORDER FORM - CANADA
IT S NOT IMAGINARY. IT S REALITY. BRINGING YOU LITTLE WAVE.
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Auftrags-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
BUDDY "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
Etac 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
4.8 MODEL WM / /2 15 1/2 16 1/ /2 15 1/2 16 1/ /2 16 1/2 17 1/2
160 Armand-Majeau Sud Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T.+1-866-650-6555 F. +1-888-966-6555 orders@motioncomposites.com www.motioncomposites.com 4.8 Helio C2 ORDER FORM - CANADA P.O. number:*