SHIPPING INFORMATION Provider Acct #:
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1 May 2014 Kids ROCK TM Size 2 Order Form Maximum Weight Capacity 115 lbs. 14"Wx16"Dx22"H Seating Capacity. Customer Service: (toll free) orders@pridemobility.com Date: Quote Order SHIPPING INFORMATION Provider Acct #: PO#: Provider: Ship To: Provider Contact: Attention: Provider Address: Address: Provider City: ST: ZIP: Address: Provider Phone: ( ) Fax: ( ) Ship To City: ST: ZIP: Ship To Phone: ( ) Fax: ( ) Confirmation DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. HCPCS codes should not be considered as legal advice. All MEASUREMENT WORKSHEET Kids ROCK Size 2 chair, Tilt-in-Space Mark For: Age: Height: Weight: ft. in. lbs. Includes: Tilt in space, non-dynamic, mobility base, Silver metallic frame color, standard configuration. E1233 Kids ROCK Chair - Size 2 $2, Transit Option Seating System and/or Back System Required for ISO Compliance.Transit Option must be factory installed and is not retrofitable. Transit Option $ Upholstery Color Upholstery Color applies to: back cushions, lateral pelvic/thigh supports, calf protector Black Vibrant Red/Black Green/Black Pink/Black Blue/Black Figure 1 - Client Measurements A. Sitting Depth B. Trunk Depth C. Trunk Width D. Hip Width E. Top of Shoulder to Seat F. Lower Leg Length Reaction TM Dynamic Seating Requires Angle Adjustable Leg Rests E2295 Kids Rock TM Active Component $ Upper Body Springs Soft - Pair Medium - Pair Hard - Pair No Springs Page 1 of 7
2 Front Rigging Required with REACTION System. Calf Protector included with all Front Rigging Option Fixed Front Rigging Lower Body Springs E0990 Angle Adj. Elevating Leg Rest $ C C C Soft - Pair Medium - Pair Hard - Pair No Springs Foot Plate K0040 Select Foot Plate Installation: Std( ".5 Leg Drop) Inverted(7.5-11" Leg Drop) Long(14"-16" Leg Drop) 90 Fixed Foot Plate Bolt Angle Adjustable Foot Plate ±8 Dorsal/Plantar Flexion; K0040 Angle Adjust Flip Up Foot Plate $ $ K0040 Quick Angle Adj. Foot Plate $ to +45 Dorsal/Plantar Flexion; 8 Positions; Easy Pull Adj. Kids ROCK 2 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 E2294 8"-11" Depth $ Ischial Insert Selection Required Open Cell Foam E "-14" Depth $ K0108 Soft Memory Foam $50.00 E "-17" Depth $ K0108 Medium Memory Foam $50.00 Kids UP LifeForm Seating System Accessories Extra Positioning Wedges (4) Pressure Relief Layer - Sunmate (14" x 16" x 1/2") $35.00 $60.00 Wedge for Seat Cushion (14" x 8" x 1") $40.00 Synergy Seat Cushion Options E2607 Synergy Solution Cushion 14"x12" E2607 Synergy Solution Cushion 14"x14" E2607 Synergy Solution Cushion 14"x16" E2607 Synergy Solution Cushion 14"x18" E2607 Synergy Solution 1 Seat Cushion 14"x14" W/Gel Layer E2607 Synergy Solution 1 Seat Cushion 14"x16" W/Gel Layer E2607 Synergy Solution 1 Seat Cushion 14"x18" W/Gel Layer Back System Options E2293 Configurable, Contoured, Adjustable Height Solid I-Back System $ Back Canes Only. (Not ISO Compliant) Page 2 of 7
3 Kids UP Lifeform Back Cushion Options Select 1 if is Selected. Back Cushions include contouring wedges and lumbar support 12"-17" Contoured Back Cushion. (I-Back) 16"-22" Contoured Back Cushion. (I-Back) Omit Back Cushion Less Block Letters Back Cushion Embroidery (Emboridery is applied to colored panel) Inscription, Please place one letter per box Script Letters Blue Thread Red Thread Black Thread Green Thread Purple Thread White Thread Basic Fixed Height Armrest Thin Profile - Pair Fixed Height Armrest Desk Length Pad - Pair * $ E0973 Adjustable Height Armrest Desk Length Pad - Pair * Armrest Options E0973 E0973 Adjustable Height Armrest Full Length Pad - Pair * Adjustable Height Armrest Thin Profile Pad - Pair Armrests with * not for use with 22" or 24" Rear Wheels Tray Options E0950 Upper Extremity Positioning Platform Color - Clear $ E0950 Upper Extremity Positioning Platform Color - Gray $ Angle/Depth Adj. Support Hardware - Req. for all trays $ Rear Wheels 16" Composite Rear Wheels 24" Composite Rear Wheels (only avail. w/ 8" Casters). Requires " Composite Rear Wheels. Requires Rear Tires E2213 Full Polyurethane w/treads Pneumatic Pneumatic w/airless Inserts $88.00 Hand Rims Chrome Hand Rims (Not Avail. With 16" Wheels) Available with 22" and 24" rear wheels only. K0108 Plastic Coated Hand Rim Upgrade (Not Avail. w/16" Wheels) $92.00 Omit Hand Rims Page 3 of 7
4 Rear Anti-Tips E0971 Rear Anti-Tips with Wheels 22"/24" Wheel Axle Options Attendant Wheel Lock Option Requires 16" rear wheels and 8" casters Adj. Position Axle System $ Attendant Wheel Lock $ Caster Options Seat pan to floor height is15.5" with5" caster, and 17.5" with 8" caster. 5" x 1.5" Poly 8" x 2" Poly Lateral Pelvic/Thigh Supports Left Pelvic/Thigh Support Pkg. $ 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, $ " 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, $ " 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 Contoured Dynamic LifeForm Zipper Opening Dynamic E0960 Contoured - Early Intervention E0960 Zipper Opening - S E0960 Contoured - XS E0960 Zipper Opening - M E0960 Contoured - S E0960 Zipper Opening - L LifeForm Contoured Structured E0960 Contoured Structured - S 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. ROCK 2 S/A Abduct. Hardware $ E0957 E0957 E0957 Small Wedge(2"-3"W x 4"L x 3"D) Med. Wedge (2"-4.5" x 5"L x 3"D) Lg. Wedge (3"-5" x 5"L x 4"D) $ $ $ Lifeform Headrest and Support Hardware E0955 8" Curved Oval Pad LifeForm Removable Headrest Mounting Hardware $ E " Curved Oval Pad (Required for all Headrest Options) E " Curved Oval Pad Universal Head Rest Mount Plate Only* $50.00 E0955 Narrow Adjustable Arc Pad $ *Accomodates several other manufacturers headrests. Call for details. E0955 Standard Adjustable Arc Pad $ Page 4 of 7
5 Lifeform Ankle and Foot Positioning Stealth Hard Side Foot Stabilizers LifeForm Ankle Hugger Foot Stabilizers K0108 Small, Pair, Left and Right $ K0108 Medium, Pair, Left and Right $ K0108 Large, Pair, Left and Right $ L K0108 Left - Small $ R K0108 Right - Small $ L K0108 Left - Medium $ R K0108 Right - Medium $ L K0108 Left - Large $ R K0108 Right - Large $72.00 Lifeform Swing Away Lateral Support Hardware Choose your bracket and CURVED pad size Choose your bracket and PLANAR pad size Left 1.5" pediatric bracket lateral thoracic support package, Curved Pad Left 1.5" pediatric bracket lateral thoracic Right 1.5" pediatric bracket lateral Right 1.5" pediatric bracket lateral thoracic thoracic support package, Curved Pad Left 2" bracket lateral thoracic support package, Curved Pad Left 2" bracket lateral thoracic support package, Planar Pad Right 2" bracket lateral thoracic support package, Curved Pad 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) Requires , 3120, 3210, Left 1.5" DoubleSwing pediatric swingaway Choose Swing-Away Hardware (required) Requires , 3120, 3210, Left 1.5" DoubleSwing pediatric swingaway Right 1.5" DoubleSwing pediatric swingaway Right 1.5" DoubleSwing pediatric swingaway Left 2" DoubleSwing Left 2" DoubleSwing Right 2" DoubleSwing Right 2" DoubleSwing LifeForm Swing-Away Width and Depth Extensions (optional) Options Available only with Swing-Away Hardware. Depth Ext. + 1", pediatric, Left Depth Ext. + 1", pediatric, Right Width Ext. + 1", pediatric, Left Width Ext. + 1", pediatric, Right Depth Ext. + 1", 2" Brkt., Left Depth Ext. + 1", 2" Brkt., Right Width Ext. + 1", 2" Brkt., Left Width Ext. + 1", 2" Brkt., Right Page 5 of 7
6 Choose your bracket and CURVED pad size Left 1.5" fixed pediatric bracket lateral thoracic support package, Curved Pad LifeForm Fixed Lateral Support Hardware Choose your bracket and PLANAR pad size Left 1.5" fixed pediatric bracket lateral thoracic Right 1.5" fixed pediatric bracket lateral thoracic support package, Curved Pad Right 1.5" fixed pediatric bracket lateral thoracic Left 2" fixed bracket lateral thoracic Left 2" fixed bracket lateral thoracic support package, Curved Pad Right 2" fixed bracket lateral thoracic Right 2" fixed bracket lateral thoracic support package, Curved 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 ROCK Sunshade $ Underchair Cargo Tray (carries up to 10 lbs) Replacement Seat Cushion Covers E2610 E2610 E2610 Replacement Cover 8"-11" Seat Cushion Replacement Cover 11"-14" Seat Cushion Replacement Cover 14"-17" Seat Cushion $ $ $ Additional Support Accessories Additional Support Accessories NOT tested with Transit. Must remove prior to tie down. K0105 IV Support Pole E1029 Battery/Vent. Accessory Tray $ Requires 16" Rear Wheels and 8" casters. E2208 Oxygen Tank Holder (Does not include vent. mount for LTV) E1029 Ventilator Tray $ for LTV Ventilator Series Only Requires 16" Rear Wheels and 8" Casters Custom Notes: Page 6 of 7
7 Page 7 of 7
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 #: 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
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:
Convaid Trekker 2 - HCPCS E1234 Retail Price List / Order Form
Account #: Contact: Retail Price List / Order Form Purchase Order #: Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email: Ship To: Address: City/State/Zip: Phone: TR14 Base Accepts TR12 & TR14
Convaid Trekker 2 - HCPCS E1234 Canadian Retail Price List / Order Form
Account #: Contact: Canadian Retail Price List / Order Form Purchase Order #: Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email: Ship To: Address: City/State/Zip: Phone: TR14 Base Accepts
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
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
FUZE T50. Order Form USA. Please send your completed order form by to or by fax to
Page 1 of 5 Purchase Order Tag Dealer/Organization Name Purchaser Name and Contact Information Mailing Address Shipping Address Please send your completed order form by email to info@pdgmobility.com or
R82 Kudu - E1233. Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features: Recline No HCPCS Code Assigned to Kudu sz 4
Account #: Purchase Order No.: Contact: R82 Kudu - E1233 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
R82 Kudu - E1233. Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features: Recline No HCPCS Code Assigned to Kudu sz 4
Account #: Purchase Order No.: Contact: R82 Kudu - E1233 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
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
JAY Fit. Backrest and Seat Assembly. July 2017
JAY Fit Backrest and Seat Assembly July 2017 Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention:
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: ( )
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.
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
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
Quickie IRIS FSS Net Order Form/Price List (SIN F-1)
Mark For: Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: Dealer Phone: ( ) Fax: ( ) Confirmation Email: Confirm Via: ZIP: Quickie IRIS FSS Net Order Form/Price List (SIN
[ ] Quote [ ] Order. Junior US Retail Price List. Account Information. Ship To Information. Standard Features.
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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
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:
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
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)
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
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
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.
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 v.070118 Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Shipping Address * * required F r a
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:
Frame Width. Seating Setup. q 16 q 15 q 14 q 17 q 16 q 15 q 14 Short q 18 q 17 q 16 q 15 q 14 q 19 q 18 q 17 q 16 q 15 q 14
Phone 0800 5 Fax 0800 5 365 Funder: Account Number: Date: Quote PO Number: Therapist: Marked For: Focus CR $ 36kg weight capacity. Tilt range: -5º anterior to 50º posterior. Effective /0/0 Ship To: Address:
USA Parts List FUZE T50
USA Parts List FUZE T50 Effective January 1, 2018. Prices in U.S. Dollars. Prices and descriptions contained in this manual are subject to change without prior notice. Fuze T50 Frame-Seat Pan Cross Bar
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
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
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
USA Parts List FUZE T20
USA Parts List FUZE T20 Effective January 1, 2018. Prices in U.S. Dollars. Prices and descriptions contained in this manual are subject to change without prior notice. Fuze T20 Frame-Seat Pan Cross Bar
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
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
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
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
STELLAR GL. 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.070118 Shipping Address * * required F r a
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
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:
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
FUSION Seating Prescription Form Custom Built Seating System
GENERAL INFORMATION Clinician: Email: Date: Service: Delivery Address: Client Name/Ref: Address/School: Current Equipment: Issues with Current Equipment: Observations, deformity: Hips/Pelvis: Spine/Trunk:
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
C300 Corpus Tilt. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the
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
R82 Stingray. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: City/State/Zip: Effective: 2/01/ Rev 7.
R82 Stingray CAD 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: Phone: US Configuration
USA Parts List BENTLEY
USA Parts List BENTLEY Effective January 1, 2018. Prices in U.S. Dollars. Prices and descriptions contained in this manual are subject to change without prior notice. Bentley Frame-Seat Pan Floor Jack
Chair Back Solid. Chair Back. Chair Back. Chair Back
Seats and Backs Seats and Backs Solid Up to 14 x 14... 0625 Up to 18 x 18... 062501 Up to 22 x 22... 062502 I-Modification Up to 14 x 14... 06258 Up to 18 x 18... 062510 Up to 22 x 22... 062511 T-Modification
Phone: Jan 17. Fax: usa.com Quote: P.O. usa.com Bill To
By Ormesa New 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 800 327 0681 Jan 17 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility usa.com Bill To Dealer:
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
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:
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
JAY AES - QUICK ORDER FORM November 2012
JAY AES - QUICK ORDER FORM November 2012 Account: Date: Job #/PO#: User Name: Contact: Ship To: Name: Address: City,State,Zip: Phone: 1. WHEELCHAIR INFORMATION (REQUIRED) 3. SEAT DIMENSIONS Model: Model:
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
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
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Canada AADL CAT # 151 Effective 10/01/2018 Company: Account Number: Date: q Quote q PO Number:
q q q q q q q q q q q q q q q q q q Frame q Titanium Frame K5-CAT5-TITAN $ Includes hangers and base frame. Does not include Cross Braces.
Funder: Order Number: Date: q Quote q PO Number: Therapist: Marked For: Catalyst 5 K5-CAT5-ALI 136kg weight capacity Frame Seat Width / Seat Depth Select box corresponding to desired Seat Width and Depth
KID-KART TLC... 3 BASE... 3 BASE - Discontinued... 3 SILVER BASE... 4 CASTER FORK ASSEMBLIES... 5 WHEEL LOCKS... 6 ANTI-TIPS... 7 REAR WHEELS...
KID KART TLC PAGE 1 KID-KART TLC... 3 BASE... 3 BASE - Discontinued... 3 SILVER BASE... 4 CASTER FORK ASSEMBLIES... 5 WHEEL LOCKS... 6 ANTI-TIPS... 7 REAR WHEELS... 8 STROLLER HANDLE... 9 KID KART PNEUMATIC
Quantum Rehab A Division of Pride Mobility Products Corporation
Quantum Q600 Group 3 Order Form/ODJFS Only 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)
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
Traxx 3 & Atigra 2 Script Form
Traxx 3 & Atigra 2 Script Form Client Information Address Therapist Information Organisation Email Phone Height Weight Funding Source Salesperson Information Company Traxx 3 Atigra 2 Standard Features
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
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
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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
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