Order Form. English Company stamp
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1 NONO Date User name Company stamp Rigid frame wheelchair Responsible Wheelchair measures Seat width (LS) Seat depth (PS) 27, , ,5 40 Seat depth can be increased by 2,5 or 5 cm. Footplate distance (DP) (Real distance between seat and footplate) IMPORTANT NOTICE! From the footplate to the floor minimum 4cm.!! (Minimum Front height = DP + 4cm.) Setting Standard Prudential Active Backrest Height (TS) Std.Value 33,5...(min 29 - max 51) camber Front height... (STD 45) Rear height... (STD 41) Casters 3'' (min 35 - max 51) Rear wheels 22'' (min 35 - max 45) Casters 4'' (min 35 - max 52) Rear wheels 24'' (min 37 - max 47) Casters 3'' (min 32 - max 52) Front frame Aluminium frame - Angle 95 Frame with abduction Footplate Colour aluminium frame Bright silver LS LS Opaque black LS + 6 LS + 23 LS + 17 Straight frame One piece aluminium footplate - Flip-up! FLIP-UP! - rake and depth adjustable Footplate distance (min 8 - max 38) 95 Bright blue Bright fuchsia Bright red Bright lime Pearl white Opaque orange Backrest with double locking (upright and folded) (with rake adjustable from -4 to +16 ) Aluminium backrest Handle tube Handle tube STD Folding handles aluminium Fork colour Colour rear wheels To be matched only with:rear wheels Ultra-light Progeo - Standard! (22-24) Opaque black Black Bright silver Bright blue Bright silver Bright blue Pearl white Bright fuchsia Pearl white Bright fuchsia Bright red Bright lime Bright red Bright lime Pag. 1 / 5
2 Casters 4" Soft 3" Sport 5" Soft 3" Active Soft (wide) 4" Active Sport (narrow) " Active Soft (wide) 5" Active Soft (wide) Rear wheels 24" Ultra-light Progeo - Standard! 22" Ultra-light Progeo - Standard! 24" ULTRA-LIGHT PROGEO KEY SPORT 24" Ultra-light "Spinergy LX" Weight reduction approx. 450gr. 24" Ultra-light "Spinergy LXL" Black hub and white blade spokes Hub and blade spokes black 24" Ultra-light "Spinergy Flex rim" 24" Off-road (aluminium handrim black) Rear wheel tyre High pressure tyre (22"-24") High pressure profile tyre (24") Marathon Plus (24") with anti-puncture protection Solid tyre Kik Mako - Colour Black (24") Solid tyre Kik Mako - Colour Grey (24") Handrim - Wheel distance 3 cm 4 cm Aluminium (22"-24") Aluminium black SOFT-TOUCH (24") Chromed Steel (24") Titanium (24") Ultra Grepp (24") Max Grepp (24") Ergo Para (24") SURGE LT (24") Oval countour with a rubber insert Quad (24") (24") Silicon cover for standard aluminium handrim Available for measures (22"-24"-25"-26") Wheel locks Bent lever push to lock Straight lever Push to lock Straight lever Pull to lock Brake with extension lever push to lock Brake with extension lever pull to lock Pag. 2/ 5
3 Mudguard Removable ABS mudguard Removable ABS fibre straight sideguard Removable carbon fibre mudguard Removable Carbon fibre straight sideguard Armrests Swing away armrests (Swing away, removable and height adjustable armrest) Height assembly (to the seat): 27 28, , ,5 36 Removable armrest with ABS straight sideguard Removable armrest with carbon-fiber straight sideguard Kind of pad to be mounted on chosen armrest Optional 1 Anti-tipper with rapid hookup (inside rotation to reduce the encumbrance) Optional 2 One piece Push handle for campanion Push handles for companion Tetraclip Pad for front frame protectors Safety pelvic belt Harness Pad STANDARD Ergonomic pad (30x6 cm.) Right Left (Removable and height adjustable) (Removable and height adjustable) (Quick release axle for quadriplegic) Lumbar support (to insert in the backrest upholstery) Swing away lateral support Not available with: Posture backrest PHYSIO - Posture backrest A I R Right Left Spoke guards Black (22"-24") Spoke guards Transparent (22"-24") Spoke guards Progeo design (22"-24") Spoke guards Dragon (22"-24") Additional Kit 24" Off-road rear wheels 24" FAT rear wheels Off-Road tyre - aluminium handrim (black colour) FAT tyre 3'' - aluminium handrim (black colour) Pag. 3/ 5
4 PHYSIO - Posture backrest KID Junior version - Std. Backrest upholstery not provided WARNING: with this backrest the seat depth is reduced by 5 cm approx. Aluminum shell Height SWING AWAY - Lateral support External thoracic support to the backrest width, adjustable from 0 to +3 cm adjustable from 1 to -3 cm adjustable from -5 to -8 cm Large (17,5x11,5) Large (17,5x11,5) Large (17,5x11,5) Left Left Left Right Right Right Small (14x9,5) Small (14x9,5) Small (14x9,5) Left Left Left Right Right Right PHYSIO - Posture backrest Adult version - Std. Backrest upholstery not provided not available for seat width 27 Aluminum shell - Lateral retaining STANDARD 7,5cm Height Height 52 Aluminum shell - Lateral retaining DEEP 15cm Height H25 not available for seat width 39 Height 52 Carbon shell - Lateral retaining STANDARD 7,5cm Height SWING AWAY - Lateral support Not available with Physio backrest with lateral retaining DEEP and in carbon backrest adjustable (0-1,5cm) COVER Cover with fabric-cover of backrest s rear side and high refraction fabric hems adjustable (-4-5,5cm) adjustable (-8,5-10cm) Large (17,5x11,5) Large (17,5x11,5) Large (17,5x11,5) Left Left Left Right Right Right Small (14x9,5) Small (14x9,5) Small (14x9,5) Left Left Left Right Right Right Additional Kit for internal thoracic support to the backrest width, adjustable (-8,5-10cm) (with additional kit) Pag. 4 / 5
5 Headrest adjustable - Double ball mounting system Not available for Physio backrest s height 25 and with carbon shell Large (34x14) Small (28x14) Rear wheels Model 22" Ultra-light Progeo - Standard! (not available in anthracite color) 24" Ultra-light Progeo - Standard! (available for all coulors) Features 24" ULTRA-LIGHT PROGEO KEY SPORT (silver hub, black rim and 16 spokes) 24" Ultra-light "Spinergy LX" (silver hub, black rim and spokes) 24" Ultra-light "Spinergy LXL" (black hub and rim, 18 white blade spokes) - (black hub, rim and 18 spokes) 24" Ultra-light "Spinergy Flex rim" (silver hub, black rim and spokes) - (integrated aluminium/rubber handrim - encumbrance reduction up to 3cm. - all tyre) 24" Off-road (colour: black) - (aluminium handrim - tyre Off-road) Note Italia Certified company normative UNI EN ISO 9001 Pag. 5 / 5 Wheelchair : - Printed on Prices in EURO - VAT excluded to be added to the price list Important notice! is page only if any optional have been chosen standard (supplied if no requests are indicated) on request (without extra charge) optional (cost to be added at the basic price)
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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:*
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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
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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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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:*
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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 4.7 Helio A7 ORDER FORM - INTERNATIONAL P.O.
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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
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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 4.8 P.O. number:* Date: Ship to:* Company Name:*
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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:*
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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 4.8 Helio A6 ORDER FORM - INTERNATIONAL P.O.
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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
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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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