Vision Ultra-single power
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1 Account # Dealer Name Contact Phone Date Fax PO Number Ship to Address City State Zip *HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for determining the appropriate billing codes when submitting for insurance reimbursement. Power Base Part Number HCPCS MSRP Group 2 Power Base, with 2 pole 240W motors, 300lbs weight capacity Group 2 Power base, single power K0835 $6,499 Shroud Color Part Number HCPCS MSRP White No Charge Candy Apple Red No Charge Blue No Charge Power Tilt Seating Part Number HCPCS MSRP Deluxe seat power tilt / angle-adjustable back, seat width & depth-adjustable E1002 $4,999 Electronics Part Number HCPCS MSRP Drive only VR2 Through toggle box (special order only) Through VR2 on power tilt- one actuator Through VR2 on power tilt with power AFP- two actuators P NI E2310 $1, NI E2311 $2,895 Joystick Mounting Brackets Part Number HCPCS MSRP Swing-away mounting bracket (Right) NI E1028 $250 Swing-away mounting bracket (Left) NI E1028 $250 Inline joystick (Special Order) 1 RevA1
2 Dimensions for Seating Width measured in 1" Increments Width Depth Depth measured in 1" Increments Standard Cushions Part Number HCPCS MSRP Omit seat cushion N/A N/A N/A W16 x D20 cushion N/A $129 W18 x D20 cushion N/A $129 W20 x D20 cushion N/A $129 W22 x D20 cushion N/A $129 Protekt foam, 18"x18"x3", 250 lbs cap E2601 $139 Protekt foam, 20"x18"x3", 250 lbs cap E2601 $139 Protekt foam, 22"x18"x3", 400 lbs cap E2602 $159 Protekt foam, 22"x20"x3", 400 lbs cap E2602 $159 Protekt gel, 18"x18"x3", 275 lbs cap E2603 $199 Protekt gel, 20"x18"x3", 275 lbs cap E2603 $199 Protekt gel, 22"x18"x3", 500 lbs cap E2604 $219 Protekt gel, 22"x20"x3", 500 lbs cap E2604 $219 Please Note that the Merits backrest is only compatible with the Merits headrest Standard Backrests Part Number HCPCS MSRP Omit backrest 16"W backrest with cover cloth / N/A No Charge 18"W backrest with cover cloth / N/A No Charge 20"W backrest with cover cloth / N/A No Charge 22"W backrest with cover cloth / N/A No Charge Adapter for comfort company backrest (not for use with Avid backrest or N/A No Charge Angle-adjustable back 90 degrees 95 degrees 100 degrees 105 degrees 110 degrees Armrest Options Part Number HCPCS MSRP Height-adjustable, cantilever armrests Gel Ovations Arm Accessories Part Number HCPCS MSRP Arm pad 3.5" width 12" 312G N/A $ Arm pad 3.5" width 14" 314G N/A $ " X 10" Gel Arm pad Right Left 210G N/A $ " X 12" Gel Arm pad Right Left 212G N/A $ " X 14" Gel Arm pad Right Left 214G N/A $ Gel Ovations Arm Troughs Part Number HCPCS MSRP First Trough Side - 10"L x 2"W Right Left FTS10 N/A $ First Trough Side - 12"L X 2"W Right Left FTS12 N/A $ First Trough Side - 14"L X 2"W Right Left FTS14 N/A $ Second Trough Side - 10"L X 2"W Right Left STS10 N/A $ Second Trough Side - 12"L X 2"W Right Left STS12 N/A $ Second Trough Side - 14"L X 2"W Right Left STS14 N/A $
3 Accessories Part Number HCPCS MSRP Swing-away trunk support bracket (R&L, for one unit) E1028 $499 Sta-Rite articulating regular lateral supprt hardware- Left EACH SRRLHL - $245 Sta-Rite articulating regular lateral supprt hardware- Right EACH SRRLHR - $245 Trunk support pad- L 6"x4"x1" (2pc/ pack) E0956 $79 Trunk support pad- M 5"x4" x1" (2pc/ pack) E0956 $79 Trunk support pad- S 5"x 3"x1" (2pc/ pack) E0956 $79 Swing-away abductor bracket E1028 $149 Abductor pad- M: 6"x4"x3" E0957 $54 Abductor pad- S: 4"x3.5"x3" E0957 $52 Headrest Part Number HCPCS MSRP Omit headrest Headrest 9" E0955 $150 Swing-away headrest mount NI E1028 $99 Footplate and Legrest Options Part Number HCPCS MSRP Standard center footplate with calf pads N/A No Charge Manual elevating legrest, gooseneck mount PAIR 39904M10 E0990 $179 Power articulating foot platform E1012 $2,398 Gel Ovations Footplate and Legrest Part Number HCPCS MSRP Single piece footplate gel foot protector cover GFPCS N/A $150 Gel and foam calf pad 8" X 6" X 1.5" PAIR GCP N/A $245 Sta-Rite swing-away removable residual Right Left SRSSF E1020 $350 limb support 6" X 7.5 DSSP flat Sta-Rite swing-down residual limb support bracket SRSSFHO E1028 $250 Gel Ovations Residual Limb Support Part Number HCPCS MSRP Universal elbow stop bracket and flat pad 3"x4" Right Left UESF1 E229 $45.00 Batteries Part Number HCPCS MSRP 12V, 34 Ah, U1, AGM, BWG (x2) SCPU1 E2365 $158 ea. 12V, 55 Ah, 22NF, AGM, BWG (x2) BW12550-IT E2361 $255 ea. 12V, 55 Ah, 22NF, Gel, MK (x2) M22NF E2361 $295 ea. *When ordering the version with power tilt seating, we recommend using 22NF batteries* 3
4 Vision Ultra-standard Captain Seat Pan Seat Power Base Part Number HCPCS MSRP Group 2 Power base, pan seat Group 2 Power base, captain seat Group 2 Power Base, with 2 pole 240W motors, 300lbs weight capacity K0822 $6, K0823 $6,499 Captain Seat Part Number HCPCS MSRP 18"W x 18"-20" x 20"H depth-adjustable N/A No Charge 20"W x 18"-20" x 20"H depth-adjustable N/A No Charge 22"W x 20"-22" x 20"H depth-adjustable N/A $450 (Only for Captain Seating) Pan Seat Part Number HCPCS MSRP 18"W x 18"-20" x 20"H depth-adjustable N/A No Charge 20"W x 18"-20" x 20"H depth-adjustable N/A No Charge 22"W x 20"-22" x 20"H depth-adjustable N/A $450 (Only for Pan Seating) Standard Cushions (Only for Pan Seating) Part Number HCPCS MSRP Protekt foam, 18"x18"x3", 250 lbs cap E2601 $139 Protekt foam, 20"x18"x3", 250 lbs cap E2601 $139 Protekt foam, 22"x18"x3", 400 lbs cap E2602 $159 Protekt foam, 22"x20"x3", 400 lbs cap E2602 $159 Protekt gel, 18"x18"x3", 275 lbs cap E2603 $199 Protekt gel, 20"x18"x3", 275 lbs cap E2603 $199 Protekt gel, 22"x18"x3", 500 lbs cap E2604 $219 Protekt gel, 22"x20"x3", 500 lbs cap E2604 $
5 Vision Ultra-standard Joystick Mounting Brackets Part Number HCPCS MSRP Swing-away mounting bracket (Right) NI E1028 $250 Swing-away mounting bracket (Left) NI E1028 $250 Inline joystick (Special Order) - - No Charge Armrest Options Part Number HCPCS MSRP Height-adjustable, detachable armrest (Captain seat and pan seat) Right Left / E0973 $150 Foot platform and Legrest Options Part Number HCPCS MSRP Center mount foot platform N/A No Charge Seat pan to foot platform length 10.5"-12.5" (not including cushion) Center mount foot platform - long (special order) L N/A No Charge Seat pan to foot platform length > 12.5" (not including cushion) Non-powered elevating legrests PAIR K0195 $360 Batteries Part Number HCPCS MSRP 12V, 34 Ah, U1, AGM, BWG (x2) SCPU1 E2365 $158 ea. 12V, 55 Ah, 22NF, AGM, BWG (x2) BW12550-IT E2361 $255 ea. 12V, 55 Ah, 22NF, Gel, MK (x2) M22NF E2361 $295 ea. Shroud Color Part Number HCPCS MSRP White No Charge Candy Apple Red No Charge Blue No Charge 5 RevA1
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
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:
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:
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)
Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.
AADL W592/W991 Quantum Q6 Edge 2.0 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:
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:
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:
ORDER FORM EIPW25. with CAPTAIN'S SEAT. Print pages 1-10 to exclude pictures. Buyer State Zip
ORDER FORM Print pages 1-10 to exclude pictures. with CAPTAIN'S SEAT EIPW25 Customer Account # Date PO# Ship To Name Address City Buyer State Zip Mark For Phone Client Measurements a) Top of head to seat
Quantum Q1121 Series Group 3 Single Power and Multiple Power 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) 707-3422 Quantum Q1121 Series Group 3 Single Power and Multiple Power
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
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)
M1 - NPO. Dealer Information. Client Information. Client Measurements
Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified
Quantum R4000 Series Group 3 Single Power & Multiple Power Order Form / ODJSF 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) 707-3422 Quantum R4000 Series Group 3 Single Power & Multiple Power
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
Quantum R4000 Series Group 3 Standard 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) 707-3422 Quantum R4000 Series Group 3 Order Form 300 lbs. weight capacity
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 Provider Acct #:
May 2014 Kids ROCK TM Size 2 Order Form Maximum Weight Capacity 115 lbs. 14"Wx16"Dx22"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
Traxx 3 & Atigra 2 Script Form
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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
Quantum 1103 Ultra Series Group 2 Single Power Order Form 200 lbs weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum 1103 Ultra Series Group 2 Single Power Order Form
R82 Kudu - E1233. Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features: Recline No HCPCS Code Assigned to Kudu sz 4
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Quantum 1103 Ultra Series Group 2 Static Seating 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) 707-3422 Quantum 1103 Ultra Series Group 2 Static Seating Order Form
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
Convaid Trekker 2 - HCPCS E1234 Canadian Retail Price List / Order Form
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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
Q6 Edge Z Order Form with Contoured and Synergy Seating - Group 3
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Q6 Edge Z Order Form with Contoured and Synergy Seating - Group 3 Account Number:
FUZE T50. Order Form USA. Please send your completed order form by to or by fax to
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Quantum 600 XL (HD)Series Group 3 Heavy Duty Order Form 400 lbs. weight capacity
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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:
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:
Page 1 of 13 INTRODUCTION PATIENT INFORMATION
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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
Specifications are subject to change without notice. 2018, Amylior Inc. (March 2018) AMYSEAT (Rev.0) Page 1 of 7
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1. BASE MODEL REQUIRED.
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Rival Order Form with Contoured, Synergy, and TRU-Balance Flex Seating Account
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BENTLEY. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.
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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
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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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Canada Quote / Order Form Combi
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C350 PS VR2. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
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Multi-Position Standing(MPS) System US PRICE LIST AND ORDER FORM Effective July 1, 2012
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Parts Catalog Issued: Apr 10, Pronto M94 with SureStep
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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
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
Orderform UK / IR Valid from Version 2.1 LUCA QLASS. Date:
LUCA QLASS 1 / 8 0,8 Dealer: Date: Reference No.: Quantity: Delivery address: 4.650 3.720 Basic configuration Excluding VAT - 4mph/6 km/h RWD - Fixed joystick bracket, right hand - PU side cushions - Drive
QUICKIE TANGO... 5 BASE FRAME... 5 BATTERY BOX... 5 COVERS... 6 MAIN FRAME... 7 MOTOR MOUNT & ANTI TIP... 8 SUSPENSION... 9 MOTOR...
Title - 1 - Title - 2 - Table Of Contents QUICKIE TANGO... 5 BASE FRAME... 5 BATTERY BOX... 5 COVERS... 6 MAIN FRAME... 7 MOTOR MOUNT & ANTI TIP... 8 SUSPENSION... 9 MOTORS... 10 MOTOR... 10 SEAT/BACK...
Invacare Kite (Max Seating System) Retail Max User Weight 160Kg (25 stone)
Power Wheelchair Retail Prescription Form KITEMAX160718 Tel: 01656 776222 Fax: 01656 776220 JULY 2018 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Account No : Contact No
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
Invacare Kite (Modulite Flex3 Seating System) Dealer Max User Weight 160Kg (25 stone)
Invacare Ltd Power Prescription Form Pencoed Technology Park Dealer Prescription Form Pencoed CF35 5AQ LPF1U2KITEFLEX011015Dealer Tel: +44 (0) 1656 776222 Fax: +44 (0) 1656 776220 July 2015 email: ordersuk@invacare.com
Featuring. Customer Ref: TDX2 Ultra
Featuring Class leading shear reduction with our ESR Mechanism Achieve the perfect fit with simple and precise adjustment features Maximise comfort and pressure relief with the advanced tilt and recline
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
ATP MOBILITY ASSESSMENT FORM
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Invacare Storm4 Easy Adapt Retail Max User Weight 150kgs (23.5 stone) Standard Features
Power Wheelchair Retail Prescription Form STORM4EA010117 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2017 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
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Title - 1 - Table Of Contents ZIPPIE SALSA R2 / ZIPPIE SALSA M2... 4 FRAME AND BATTERY BOX... 4 ZIPPIE SALSA R2 - CHASSIS... 4 ZIPPIE SALSA M2 - CHASSIS... 5 ZIPPIE SALSA R2 - SEAT HEIGHT EXTENSION KIT...
Q6 Edge Z Order Form with TRU-Balance 3 Positioning - Group 3, ODJFS Only
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Q6 Edge Z Order Form with TRU-Balance 3 Positioning - Group 3, ODJFS Only Account
Power. Compact yet powerful at home outside as well as inside! Configured Salsa with Comfort Seating and powered elevating legrests
Compact yet powerful at home outside as well as inside! Configured Salsa with Comfort Seating and powered elevating legrests Compact dimensions for indoor mobility Low seat height for easy table access
The order form has (MSRP) retail prices, but your price is at least 25% less than retail price. Multiply retail by.75 or call or for a quote.
The order form has (MSRP) retail prices, but your price is at least 25% less than retail price. Multiply retail by.75 or call or email for a quote. The order form has (MSRP) retail prices, but your price
Standard Base Price : 2,950. Standard Features
Power Wheelchair Retail Prescription Form PRONTOM41PP010716 Tel: 01656 776222 Fax: 01656 776220 JULY 2016 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
Quickie QX July 2017
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[ ] 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
M1 - NPO. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
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Quickie QM-7 Series. Live Without Limits. Available in Eight Group 3 and Group 4 Models:
Power Portfolio Live Without Limits The Quickie QM-7 series offers a high-performing, reliable, and stylish mid-wheel drive power solution for a client who qualifies for a Group 3 Standard (QM-710), Group
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
Setting a new standard in powered wheelchairs
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Q6 Edge 3 Order Form with Contoured, Synergy, and TRU-Balance Flex Seating
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Q6 Edge 3 Order Form with Contoured, Synergy, and TRU-Balance Flex Seating Account
Quickie QM-7 Series. Live Without Limits. Available in Eight Group 3 and Group 4 Models:
Power Portfolio Live Without Limits The Quickie QM-7 series offers a high-performing, reliable, and stylish mid-wheel drive power solution for a client who qualifies for a Group 3 Standard (QM-710), Group
Jupiter. Uncompromised comfort and postural support in keeping with a contemporary home setting
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Q6 Edge 3 Order Form with Contoured, Synergy, and TRU-Balance Flex Seating
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Q6 Edge 3 Order Form with Contoured, Synergy, and TRU-Balance Flex Seating Account
PRESCRIPTION FORM. Delivery address. Purchase order. Shipment date Delivery Date. Type
PRESCRIPTION FORM Distributor Branch Client Phone Delivery address (Use 'Shift'+'Enter' for new line) Salesperson E-mail Purchase order Type Date Shipment date Delivery Date Important Demo Request Order
Client Information and Specifications:
Model: Frontier V6 Hybrid Rear Wheel Drive 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 260 665 2769 Nov 17 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility