Synthesis Tilt Recliner Model: V4
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- Rosamund Ray
- 5 years ago
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1 PO: Date: Customer #: Customer Name: Address: Phone: Contact: Ship To Name: Address: Phone: Contact: Tag: Standard Features Comfort Tension Seating 350lb Weight Capacity Up to 40 Infinitely Adjustable Seat Tilt Trendelenburg Capable Up to 90 Infinitely Adjustable Back Recline Elevating and Articulating Legrest 2 x 6" Rear Multi-Directional Locking Casters 2 x 5" Total Lock Front Casters Height Adjustable, Swing-Away Removable Arms Height and Width Adjustable Upper Laterals (Wings) Synthesis Tilt Recliner - Model: V4 MSRP $3,674 Seat and Back Options Seat Width: 16" 18" 20" Seat Depth: 17" Standard 22" $ " 24" 26" $946 20" $100 Seat Height: 19.5" $180 Back Height: 32" Standard 20.5" Standard 33.5" $100 22" 23.5" $180 35" $100 Front Options Wheel Options Rear Options 5" Total Lock Front Casters Standard 6" Multi-Directional Locking Rear Casters Standard 5" Aluminum Non-Locking Front Casters $190 14" Rear Mags 14" Mid Mags $332 (available with rear mags only) 20" Rear Mags $332 5" Front Locking Twin Wheel Casters $190 Wheel Lock Extension Handles (pair) $64 Elevating Footrest Options (Select One) Adjustable Elevating Split Footrest (not available in 16" seat width) Standard (Choose number of straps) Adjustable Elevating Single Footrest (Choose number of straps) ABS Elevating Leg & Footrest (Includes calf and sole pads) (16" - 24" Widths) $344 Armrest Options Armrest Soft Armrest Standard Armtop Height Adjustable Arms Standard Options: Long Armrest $42 Style: Height and Depth Adjustable (pair) $138 Padded Armrests (pair)(black) $80 Armtop n Seat Mounted Arms Standard Arm Trough (each) $136 Mount: Base Frame Finish Color (Select one) Carmine Red Ocean Blue Midnight Black Satin Nickel Tungsten Sand Bronze PSOF 02-ORDER-029MAR17 1
2 Upholstery Color Options (Select one) * Standard padding configuration: Headrest, exterior of shoulder bolsters, upper and lower side pads & sole pads Come in Accent Color. Seat, back and calf pads, and interior of shoulder bolsters come standard in Savoy Black Vinyl. ** Indigo, Espresso & Graphite are available on seat, back & calf pad & most accessories. See below under padding for selection. *** In honor of our Veterans Service, Camo options are now available. Standard Padding*: Shown with Geyser Upholstery & Accent Padding**: Shown with Indigo Upholstery & Black Tungsten Sand Frame Color Frame Color *Chair Shown with ABS footrest Upholstery Accent Color* (Select One) Vinyl: Polyurethane: Indigo** Interlace Espresso** Graphite** Portobello Geyser Fossil Forge Black Smoke House Chocolate Camo Nylon:*** (with performance finish) Digital Camo Green Retro Camo Jungle $130 Padding - Choose Option 1 OR 2 Option 1 - BRODA Padding Standard BRODA Padding: Includes: In Accent Color: Headrest, Exterior Shoulder Bolsters, Upper & Lower Side Pads & Sole Pads*. In Black Vinyl: Seat & Back Pads with Covers, Calf Pad & Interior Shoulder Bolsters Seat, Back & Calf Black Vinyl Standard Pad Cover Options: Accent Color* ***(For Indigo, Espresso or Graphite only) Full vinyl Wrap Seat & Back Pads $100 (Select Black Vinyl OR Accent Color Vinyl Above) Calf Pad Color (Select Black Vinyl OR Accent Color Vinyl Above) Grey Terry White Terry HSP Padding Package: Includes Shoulder Bolsters Long, Thigh Belt & Footbox Long $544 T-Belt Color: Black Vinyl Accent Color Vinyl Footbox Long Color: Black Vinyl Accent Color Vinyl Optional Elevating Fixed Footrest Option 2 - BRODA APP (Additional Positioning Package) BRODA APP Padding Package Includes: Seat Cushion, Back and Head Support, Foot & Calf Support, Upper & Lower Side Pads Seat Width: 16" 18" 20" Seat Depth: 17" 19" 21" $522 22" 24" 17" 19" 21" $628 26" 17" 19" 21" $734 Acute Care Padding Package: Includes: Full Vinyl Covers, ABS Footrest with Calf and Sole Pads (Factory installed)(skip footrest and padding $476 package section above when selecting this option)(16"-24" widths) PSOF 02-ORDER-029MAR17 2
3 Common Accessories Seat Belts: S-BELT Seat Belt Center Buckle Side Buckle $52 S-BELT-A Seat Belt Auto Buckle Center Buckle Side Buckle $52 S-BELT-PD Seat Belt Padded $76 S-BELT-PD-A Seat Belt Padded Auto Buckle $76 Thigh Belts: T-BELT Padded Thigh Belt $122 (not compatible T-BELT-A Padded Thigh Belt Auto Buckle $126 with BRODA APP T-BELT-NEO Padded Thigh Belt Neoprene $122 padding option) T-BELT-NEO-A Padded Thigh Belt Neoprene Auto Buckle $126 Common Accessories (Continued) Trays: TRAY-ABS Tray ABS with Strap Sewn Tray Strap Grey Black $312 TRAY-ABS-OVR Tray ABS with Strap (24" - 26" width) Black Only $448 TRAY-CLEAR Tray Clear with Strap Sewn Tray Strap $322 TRAY-HALF Half Tray (side specific)(includes upper side pad) $428 TRAY-COVER Tray Cover (padded)(for TRAY-ABS) $158 Stabilizers: STABIL-FR Front or Rear Mounted Stabilizers (select one)(pair) $90 STABIL-LAT Lateral Frame Stabilizers $158 Other: IV-POLE IV Pole & Holder (includes mounting bracket) - Front or Rear Mount $100 O2-HOLDER O2 Holder (includes mounting bracket) - Front or Rear Mount $168 Common Padding Upgrades Headrests: NR-C Headrest Contoured Pad $106 Omit Standard NR-CV Headrest Visco Foam Contoured Pad $106 Headrest Less $64 NS Neck Support $106 Positioning: SR Side Reduction Pads (pair) $100 CC-LTS Comfort Company Lateral Supports $472 LTS Lateral Torso Supports (FACTORY INSTALLED RECOMMENDED) $580 SB-LONG-V4 Shoulder Bolster Long (pair) - Omits standard short $286 Footrest Pads: FB-SH Footbox - Extended Pad Omit Calf and Sole $300 FB-LONG Footbox- Full Extended Pad Pads Less $178 $344 Additional Options: Delivery Instructions or Special Requests: Total: $ PSOF 02-ORDER-029MAR17 3
4 PSOF 02-ORDER-029MAR17 4
5 . PSOF 02-ORDER-029MAR17 5
Index. By Chair Model. Accessory Cushions & Parts. Seat & Back Pads. Positioning Belts. Trays. Footrests. Cylinders & Cables. Stabilizers/Anti-Tippers
Parts & Accessories Index By Chair Model Accessory Cushions & Parts Seat & Back Pads Positioning Belts Trays Footrests Cylinders & Cables Stabilizers/Anti-Tippers Page Elite 2 MIDLINE 3 30VT 4 Pedal Chair
Rest Assured. Broda Chairs Patented Designs Benefiting Residents and Caregivers
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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
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
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
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:
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
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
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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
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
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JIVE F/R: 5,650 9,193 JIVE M: 5,895 9,591
Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: Country: Country: Tel: Fax: Tel: Fax: Order date: Marked for: Purchase order: Standard Features Angle adj. footplate
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
R82 Stingray - E1233
Account #: Purchase Order No.: Contact: R82 Stingray - E1233 USD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US
Standard Base Price: 618
Manual Wheelchair Retail Prescription Form ACTION4NGHD11112016 Tel: 01656 776222 Fax: 01656 776220 JAN 2017 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref: Contact
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
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....
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
Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.
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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:
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
Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018
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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
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
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M1 - NPO. Dealer Information. Client Information. Client Measurements
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Orderform UK / IR Valid from Version 2.1 LUCA QLASS. Date:
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Tilt in space up to 60 degrees Comfort seating Max. user weight: 113kg. Height adjustable folding back Heavy Duty version 158kg
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Please choose the seat width for accessories: 35 cm 40 cm 43 cm 45 cm 50 cm
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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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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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