6.900,00 CUSTOMIZATION. SEAT WIDTH (SW) Considered external tube to external tube of the frame. Seat depth 440 mm 17-1/4 inches
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1 Aria Wheels Srls Registered Office_Via della Divisione Torino, Rome - Italy Production Department_Via A.Volta 7/G Costabissara (VI) - Italy TEL. / FAX VAT id IT info@ariawheels.com Ultralight adjustable wheelchair with fixed backrest, rigid frame made of magnesium alloy, expertly bent and epoxy painted. Junction components in aluminum 7075 black anodized. Central axis, side guards, seat, footrest cover and brake clamps made in carbon fiber as standard features. Designed guidelines and certifications: UNI, ISO 7176, CE Maximum user weight: 100 kg Total weight unloaded SW 340 mm SD 380 ± 6.7 kg Transport weight SW 340 mm SD 380 ± 4.0 kg We reserve the right to deliver a tolerance of ± 10mm on the following measurements: SW, SD, BRh, SHf, SHr e KHl We reserve the right to make technical changes without notice 6.900,00 WITH STANDARD FEATURES (VAT and shipping cost not included) In some countries the price may change by 15% CUSTOMER NAME: DEALER: PRODUCT SPECIALIST: DELIVERY ADDRESS: ORDER NUMBER: ORDER DATE: Before filling the boxes below regarding the sizes, please see the technical scheme in the last page. Aria Wheels Srls in order to avoid mistakes on the order form, suggests to contact a qualified person for taking the measurements. Aria Wheels can not make changes to the product after receiving the order form. CUSTOMIZATION Select your preferences with a flag in the box SEAT WIDTH (SW) Considered external tube to external tube of the frame NOT ADJUSTABLE AFTER SALE SW340 SW360 SW380 SW400 SW420 SW440 Seat width 340 mm 13-1/4 inches Seat width 360 mm 14-3/4 inches Seat width 380 mm 15 inches Seat width 400 mm 16 inches Seat width 420 mm 17 inches Seat width 440 mm 17-1/4 inches sw Between the internal faces of the side guards from +10 mm to +30mm respect to the SW selected - adjustable SEAT DEPTH (SD) Considered as the depth of the carbon fiber seat plate NOT ADJUSTABLE AFTER SALE SD360 SD380 SD400 SD420 SD440 SD460 Seat depth 360 mm 14-3/4 inches Seat depth 380 mm 15 inches Seat depth 400 mm 16 inches Seat depth 420 mm 17 inches Seat depth 440 mm 17-1/4 inches Seat depth 460 mm 18 inches
2 CUSTOMIZATION CAMBER REAR WHEELS NOT ADJUSTABLE AFTER SALE CBR0 CBR3 Camber 0 Camber 3 Considered from the front end of the seat plate to the tube of the footrest SEAT TO FOOTREST (StF) StF120 From seat to footrest 120mm 4-3/4 inches StF140 From seat to footrest 140mm 5-1/2 inches StF160 From seat to footrest 160mm 6-1/2 inches NOT ADJUSTABLE AFTER SALE CENTER OF GRAVITY (CG) Considered from the backrest foam to the axle of the rear wheels CG110 CG120 CG130 CG140 Center of gravity 110 mm 4-1/4 inches Center of gravity 120 mm 4-3/4 inches Center of gravity 130 mm 5-1/4 inches Center of gravity 140 mm 5-1/2 inches KNEE TO HEEL LENGTH (KHL) Considered from the footrest cover to the the seat plate KHL300 Knee to heel length 300 mm 11-3/4 inches KHL310 KHL320 KHL330 KHL340 Knee to heel length 310 mm 12-1/4 inches Knee to heel length 320 mm 12-1/2 inches Knee to heel length 330 mm 13 inches Knee to heel length 340 mm 13-1/4 inches Some measures may not be available as they are connected to the SHF dimension and to the size of the front wheels. KHL350 Knee to heel length 350 mm 13-3/4 inches KHL360 Knee to heel length 360 mm 14-1/4 inches KHL370 Knee to heel length 370 mm 14-1/2 inches KHL380 Knee to heel length 380 mm 15 inches KHL390 Knee to heel length 390 mm 15-1/4 inches KHL400 KHL410 KHL420 KHL430 KHL440 Knee to heel length 400 mm 15-3/4 inches Knee to heel length 410 mm 16-1/4 inches Knee to heel length 420 mm 16-1/2 inches Knee to heel length 430 mm 17 inches Knee to heel length 440 mm 17-1/4 inches The indicated measures are not available with 5 front wheels.
3 CUSTOMIZATION SEAT HEIGHT REAR (SHR) Considered from the floor to the back of seat plate SHR360 Seat height rear 360 mm 14-1/4 inches 250,00 SHR370 Seat height rear 370 mm 14-1/2 inches 250,00 SHR380 Seat height rear 380 mm 15 inches 250,00 SHR390 Seat height rear 390 mm 15-1/4 inches SHR400 Seat height rear 400 mm 15-3/4 inches SHR410 Seat height rear 410 mm 16-1/4 inches SHR420 Seat height rear 420 mm 16-1/2 inches SHR430 Seat height rear 430 mm 17 inches N.B.: With 25 rear wheels the measures shown are to be considered increased by ± 12.7mm 1/2 If your choice is one of the following dimensions: SHR360 SHR370 SHR380 SHF450 SHF460 SHF470 will be charged the indicated extra price SEAT HEIGHT FRONT (SHF) Considered from the floor to the front of seat plate SHF450 Seat height front 450 mm 17-3/4 inches 250,00 SHF460 Seat height front 460 mm 18-1/4 inches 250,00 SHF470 Seat height front 470 mm 18-1/2 inches 250,00 SHF480 Seat height front 480 mm 19 inches SHF490 Seat height front 490 mm 19-1/4 inches SHF500 Seat height front 500 mm 19-3/4 inches SHF510 Seat height front 510 mm 20 inches SHF520 Seat height front 520 mm 20 inches-1/4 inches N.B.: With 25 rear wheels the measures shown are to be considered increased by ± 12.7mm 1/2 If your choice is one of the following dimensions: SHR360 SHR370 SHR380 SHF450 SHF460 SHF470 will be charged the indicated extra price BACKREST HEIGHT (BRH) Considered from the seat plate to the top of the backrest BRH240 BRH255 BRH270 BRH285 BRH300 BRH315 BRH330 BRH345 BRH360 BRH375 BRH390 BRH405 BRH420 BACKREST ANGLE (BRA) Considered as the angle than the floor BRA86 BRA88 BRA90 BRA92 BRA94 Backrest height 240 mm 9-1/2 inches Backrest height 255 mm 10 inches Backrest height 270 mm 10-3/4 inches Backrest height 285 mm 11-1/4 inches Backrest height 300 mm 11-3/4 inches Backrest height 315 mm 12-1/2 inches Backrest height 330 mm 13 inches Backrest height 345 mm 13-1/2 inches Backrest height 360 mm 14-1/4 inches Backrest height 375 mm 14-3/4 inches Backrest height 390 mm 15-1/4 inches Backrest height 405 mm 16 inches Backrest height 420 mm 16-1/2 inches Backrest angle 86 Backrest angle 88 Backrest angle 90 Backrest angle 92 Backrest angle 94 Size 1 Size 4 Size 1 Size 4 Size 1 Size 4 Size 1 Size 4 Size 1 Size 4 Size 2 Size 5 Size 2 Size 5 Size 2 Size 5 Size 2 Size 5 Size 3 Size 6 Size 3 Size 6 Size 3 Size 6 Size 3 Size 6 The sizes indicated refers to the shells dimension of the postural backrests. See the dedicated order form. NOT ADJUSTABLE AFTER SALE
4 OPTIONS BRAKES BRKASL Aria Scissor lock BRKOPL Out-Front Push to lock 110,00 BRKOSL Out-Front Scissor lock 150,00 FRAME COLOR Epoxy painting FRMCWU FRMCBU FRMCVU FRMCYU White Black Light Green Yellow FRMCC Custom color Indicate the desired RAL color number 360,00 REAR WHEELS RWHAG RWHSG Without rear wheels RWHAG.1 Golz Black Wheel with black hub and black spokes RWHSG.1 Golz Six-Star with black hub and black spokes - 200,00 675,00 RWHTS RWHTS.1 Golz Twin-Star Exchange with black hub 1.000,00 Black spokes White spokes Red spokes 70,00 Blue spokes 70,00 70,00 Yellow spokes 70,00 Orange spokes 70,00 RWHAL RWHAL.1 Spinergy Lite Extreme LX with black hub 810,00 Black spokes Red spokes Blue spokes Green spokes White spokes Yellow spokes Orange spokes Purple spokes HANDRIMS HDRMB Black anodized aluminum HDRMS Silver anodized aluminum HDRMT Aluminum with foam coated for tetraplegic 130,00 HDRMTI Titanium 495,00 Not available with rear wheels Golz Six-Star ( RWHSG / RWHSG.1 ) REAR WHEELS TYRES WTSWR Schwalbe Right Run - Black/Grey WTSHX Solid polyurethane 95,00 WTSWM Schwalbe Marathon Plus Evolution - Black 95,00 WTSWO Schwalbe One - Black 125,00
5 OPTIONS FORKS FRKDS2 FRKMNA FRKFC Aria Double-Sided - black anodized aluminum Aria Single-Sided - black anodized aluminum 195,00 Aria Single-Sided - in carbon fibre 310,00 FRONT WHEELS FRWH4 4 Wheels black anodized aluminum FRWH5 5 Wheels Black anodized aluminum FRWC4 4 Wheels in carbon fibre 180,00 The 5 front wheels are only available with 25 rear wheel SIDE GUARDS CARB3 CARB3.1 Carbon Fiber Rigid Carbon Fiber Fendered 290,00 TENSION BACKREST / POSTURAL BACKRESTS BKRTT Aria adjustable Tension Backrest BKRTA Aria postural backrest aluminium 305,00 BKRTR Aria rigid postural backrest - carbon fibre 380,00 BKRTS Aria semi-rigid moisture-wicking postural backrest - carbon f. 410,00 BKRTT BKRTA BKRTR BKRTS The Aria backrest support is compatible with the Tarta Original and Tarta Emys backrests NOTE AGGIUNTIVE:
6 ARIA ACCESSORIES SEAT CUSHION IMBOTT7 Cushion made of foam with breathable textile 85,00 PUSH HANDLES PHY1 PHY Pair of adjustable push handles - black matte painted aluminum 110,00 Adjustable push handles - black matte painted aluminum 110,00 Supplied only with Aria postural backrests BACKPACK BKPY Black cordura backpack with breathable textile 130,00 UNDER SEAT BAG USBG Black cordura under seat bag with velcro fabric 60,00 ANTI TIPPER ATPR Anti tipper mounted on left - black matte painted aluminum 145,00 ATPR Anti tipper mounted on right - black matte painted aluminum 145,00 CALF BAND CLFB6L Calf band, height 6 cm - black leather SCRATCH-RESISTANT PROTECTION FRMP A pair of frame protection made of black leather - velcro fabric 70,00 CODES - OPTIONAL AND ACCESSORIES CLFB8 FRWH4 USBG CLFB6L FRWC4 FRMP IMBOTT7 BKPY FRWH5
7 CODES - OPTIONAL AND ACCESSORIES FRKDS2 FRKFC RWHAG RWHSG RWHTS FRKMNA CARB3 CARB3.1 BRKASL BRKOPL BRKOSL RWHAL HDRMS HDRMT WTSHX WTSWO HDRMB HDRMTI WTSWR WTSWM ATPR PHY PHY1
8 83 1 ± 5 mm SW ± 5 mm BRA dal suolo to floor TECHNICAL SCHEME StF ± 50 mm 1 BRH SD KHL SHF SHR CG 1 2 TW The technical scheme do not consider the dimensions of any postural and anti decubitus cushions. SW: Considered external tube to external tube of the frame. The dimension between the internal faces of the side guards is +10 mm than the SW. BRH: Considered from the seat plate to the top of the backrest. SD: Considered as the depth of the seat plate. The seat plate can be slided of 20 mm in order to follow the different angles of the backrest. CG: Considered from the backrest foam to the axle of the rear wheels. FD : Frame Deapth = (SD -10mm) + 120mm + StF. Backrest foam, thickness 30 mm. FD TD For a right sizing of the wheelchair is recommended: 1 2 SW Seat Width _ There must be a space of ± 5 mm between the user basin and the side guards SD Seat Depth _ There must be a space of ± 50 mm between the user's popliteal fossa and the rigid carbon seat. TOTAL WIDTH (TW) With Camber 0 SW ± 170 mm With Camber 3 SW ± 215 mm TOTAL DEPTH (TD) SD + StF + 120mm + 100mm + (100mm - CG) TOTAL WEIGHT With rear wheels ± 7.2 kg TRANSPORT WEIGHT Without rear wheels ± 4.5 kg
820,00 610,00 760,00 ARIA POSTURAL BACKRESTS IN CARBON FIBRE AND ALUMINIUM. Aria Wheels Srls CUSTOMER NAME: DELIVERY ADDRESS: ORDER NUMBER: DEALER:
Aria Wheels Srls Registered Office_Via della Divisione Torino, 92 00143 Rome - Italy Production Department Via A.Volta 7/G 36030 Costabissara (VI) - Italy TEL. / FAX +39 04441322533 VAT id IT 12848301003
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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
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:
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
APEX 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:*
4.6. 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:*
Invacare 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:
Quickie 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
VELOCE 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:*
4.1 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
4.2. 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
4.6. 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:*
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
Transformer. 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
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
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 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:
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.
October 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:
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.
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
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
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
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:*
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
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
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:
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
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
Custom Manual Options & ACCESSORIES AUSTRALIA 2013
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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.
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
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
Height adjustable footplates, equipped with nylon heel loops. Standard with maintenance free PU front (7 ) and rear wheels (24 ).
Excel G-lite + Compact foldable aluminium wheelchair Perfect for taking with you wherever you go due to its light transport weight and compact size. Comfortable back upholstery. Height adjustable comfortable
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:*
RESIST CONFORMITY. GO ROGUE.
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4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required MVMA053 MVMA056. MVMA058 English Manual (STD) Dutch Manual
160 Armand-Majeau Sud 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 4.8 MOVE ORDER FORM - INTERNATIONAL P.O.
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
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:*
Adult Manual Wheelchairs. Etac Cross 5 Active. Creating stability for activity
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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:*
Order no.: ... Date Signature. Posterior seat height
Start M6 Junior Scripted Order no.: Start M6 Junior Lightweight wheelchair Article number: 480F53=60000_K Provide estimate only Order Billing address/customer number Ottobock START_M6_647F263=EN-05-1510
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
YOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP.
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IT S NOT IMAGINARY. IT S REALITY. BRINGING YOU LITTLE WAVE.
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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
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PRODUCT CATALOGUE Hi, 36 years ago, I was injured in a racing accident. I realised quite quickly that if I wanted a good wheelchair I was going to have to build it myself. What was I looking for? Well,
TABLE OF CONTENTS VELOCE
PARTS MANUAL TABLE OF CONTENTS FRAME CROSSBRACE ASSEMBLY CROSSBRACE KIT CENTRAL SHAFT KIT 6 BASE SHAFT KIT 7 LINK KITS 8 LINK DIMENSION TABLE 9 MOUNTING PLATE 0 BACK WHEELS HANDRIMS SPOKES GUARD FRONT
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