4.2. Ship to: Vendor: Name: Date: Address: Ordered by: Phone:
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1 519, J-Oswald Forest, suite 101 Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T F orders@motioncomposites.com MOVE ORDER FORM - CANADA Account: PO: Ship to: Vendor: Name: Date: Address: Ordered by: City: Province: Postal Code: Marked for: Phone: User manual: English Français Taxes not included MODEL 1 MVWC01 Ultralight MOVE wheelchair aluminum. Basalt Black (250 lbs. weight capacity) WM $ MVWC09 Heavy duty kit (350 lbs. weight capacity) WAMF $740 FRAME COLOR (with black aluminum crossbrace) 3 MVFC01 Basalt Black STD 4 MVFC03 Sunkissed Orange Burgundy Sapphire Blue Monster Green Charcoal Fuchsia Steel Blue Ferrari Red Acid Green $270 5 MVFC99 Custom Color Specify color: $400 SEAT WIDTH 3 6 MVSW14 Seat width: 14" 16" 18" 1 NC 7 MVSW20 Seat width: 20" 1 22" 2 WAMA $285 SEAT DEPTH 8 MVSD16 Seat depth: 16" 18" NC 9 MVSD20 Seat depth: 20" WAMB $215 1: Available with HD kit 2: Only available with HD kit 3. Width calculator 8 BEND BACK (with fixed height push handles) 10 MVBC01 Aluminum back cane 16" 20" NC 8 BEND ADJUSTABLE ANGLE BACK (with fixed height push handles) 11 MVBC02 Aluminum back cane 16" 20" $ Select back cane angle: PUSH HANDLES OPTIONS 13 MVPH04 Stroller handle (not available with the HD option) WAMW $ MVPH03 Folding Stabilizer bar $250 T F November 19, of 7
2 SEATING CUSHIONS 15 MVSC01 2" Cushion $ MVSC02 3" Cushion $ nxt FIT cushion series (See nxt FIT pricelist) See pricelist BACK UPHOLSTERY 18 MVBH01 Slip on back upholstery NC 19 MVBH02 Adjustable tension back upholstery WAMD/WAME $ Omit back upholstery NC RIGID BACK 21 nxt back series (See nxt back pricelist) See pricelist FLIP BACK ARMREST (Convertible to T" armrest) Height Adjustment Removable function 22 MVAR01 10" Desk Length 8-12" 10-14" Locked Unlocked $ MVAR02 14" Full Length 8-12" 10-14" Locked Unlocked $370 T" ARMREST Height Adjustment 24 MVAR03 10" Desk Length 8-12" 10-14" $ MVAR04 14" Full Length 8-12" 10-14" $350 SWING-AWAY FOOTREST Set Length at: 26 MVFR01 60 swing away footrest, Length adjustable Set at: $ MVFR02 70 swing away footrest, Length adjustable Set at: $ MVFR10 Elevating legrest with calf pad, 14 to 20 length adjustable * Left Right Set at: WAMK $ MVFR11 Length modification, between 12.5" and 13.5" Set at: $90 *The elevating legrest replaces the footrest. If the same side footrest is required, it will need to be ordered separately. STUMP SUPPORT (Height and angle adjustable) 30 MVFR12 Swing away stump support: 8" x 11" Left Right SEFND0005 $375 FOOTPLATES 31 MVFP01 Standard (Composites) STD 32 MVFP03 Adjustable angle (Aluminum) WAMJ $ MVFP08 Length adjustable heel loop NC 34 MVFP09 Calf strap $50 35 MVFP10 Padded calf strap $80 T F November 19, of 7
3 CASTERS 36 MVCA01 Composite wheel w/ PU tire (1" width) 4" 5" 6" 7" 8" NC 37 MVCA10 Pneumatic 6" x 1 ¼" $ MVCA11 Pneumatic 8" x 1 ¼" $160 FROG LEGS CASTERS 39 MVCA02 4" x 1 ½ " $ MVCA03 Composite wheel Soft-Roll by Frog Legs 1 5" x 1 ½ " $ MVCA04 6" x 1 ½ " $ MVCA05 4" x 1 ½ " $ MVCA06 Aluminum wheel Soft-Roll by Frog Legs 1 5" x 1 ½ " $ MVCA07 6" x 1 ½ " $195 1: Soft-Roll are casters designed to absorb vibrations 4" caster 12½ 13 13½ 14 14½ 15 15½ 16 16½ 17 17½ 18 18½ * Config = Stem bolt & Fork Config* Std & 4" P1 Std & 5" P2 Std & 5" P3 Std & 5" P4 +1 & 5" P3 +1 & 5" P4 +2 & 5" P3 Std & 7" P4 Std & 7" P5 +1 & 7" P4 +1 & 7" P5 +2 & 7" P4 +2 & 7" P5 5" caster Config* 13¾ Std & 5" P2 14¾ Std & 5" P3 16 Std & 7" P1 16½ Std & 7" P1 14¼ Std & 5" P3 15½ Std & 7" P1 16½ Std & 7" P2 17 Std & 7" P2 14¾ Std & 5" P4 16 Std & 7" P2 17 Std & 7" P3 17½ Std & 7" P3 15½ Std & 7" P2 16½ Std & 7" P3 17½ Std & 7" P4 18 Std & 7" P4 16 Std & 7" P3 17 Std & 7" P4 18 Std & 7" P5 18½ Std & 7" P5 16½ Std & 7" P4 17½ Std & 7" P5 18½ +1 & 7" P & 7" P4 17 Std & 7" P & 7" P & 7" P5 19½ +1 & 7" P5 17½ +1 & 7" P4 18½ +1 & 7" P5 19½ +2 & 7" P & 7" P & 7" P & 7" P & 7" P5 20½ +2 & 7" P5 18½ +2 & 7" P4 19½ +2 & 7" P5 REAR WHEELS 45 MVRW01 Mag 20" 22" 24" NC 46 MVRW02 Newton One - spoke wheel 22" 24" NC 47 MVRW03 Newton Gravity - ultralight wheel 20" 22" 24" 25" 26" $350 TIRES Available 48 MVTI01 Soft Urethane 1 1/4 " 20", 22" 24" STD 49 MVTI02 Soft Urethane knobby 1 3/8 " 24" $ MVTI04 Soft Urethane - Shox 1" 24", 25" $ MVTI05 Pneumatic 1 3/8 " 20", 22", 24", 25", 26" $ MVTI06 Pneumatic HP - Schwalbe Right Run 1" 20", 22", 24", 25", 26" $ MVTI07 Pneumatic HP - Schwalbe Marathon Plus 1'' 24", 25", 26" $ /4" 16 1/4" 19 FRONT Seat-to-floor Height - Please circle your choice 6" caster Config* 7" caster 14 1/4" 15" 16" 16 1/4" 17" 15 1/4" +2 & 7" P5 16" 17" 17 1/4" 18" 17" 18" 18 1/4" Config* REAR Seat-to-floor Height +/- 1/4" - Please circle your choice 20" 22" 24" 12 1/4" 13" 14" 14" 17 1/4" 18" 19" 19 1/4" 20" 25" 14 1/4" 15" 15 1/4" 8" caster 26" 15" 16" 19" Config* T F November 19, of 7
4 HANDRIMS Assembly Available 54 MVHR01 Aluminum anodized 20", 22", 24", 25", 26" STD 55 MVHR02 Plastic coated 20", 22", 24", 25", 26" WAMO $150 Regular 56 MVHR03 Q-Grip High friction Neoprene coated* Narrow* 22", 24", 26" WAMO $ MVHR05 Surge LT handrim* 22", 24" $370 (oval aluminum handrim w/ a rubber high friction strip) 58 MVHR04 Natural Fit- Standard grip* (oval aluminum handrim w/thumb piece) 22", 24", 26" $370 Orange, White, 59 A7HR06 BBraver (ultra-performance aluminum handrim, adjustable) 24", 25", 26" See pricelist Black 60 Omit handrim NC * Not available with Mag wheels AXLES (0 camber) 61 MVAX01 Quick release axle WAMU STD 62 MVAX02 Permanent axle NC 63 MVAX03 Quad release axle WAMU $170 AXLE PLATE 64 MVAX04 Amputee adjustable axle plate (may interfere with swing away armrest) WAMT $240 WHEEL LOCKS 65 MVWL01 Push to lock STD 66 MVWL02 Pull to lock NC 67 MVWL03 6" removable extension handle $65 68 MVWL04 Newton Grade aid push to lock (suggested with pneumatic or high pressure tire) WAMR $ MVWL06 Attendant Lock (additional set of wheel lock mounted to the back) $220 POSITIONING BELTS (2 point seatbelt attachment hardware is included) 70 MVSB01 Velcro adjustable $40 71 MVSB02 Auto buckle $50 72 MVSB03 Additional attachment hardware for 4 point seatbelt $12 73 MVSB04 BodyPoint Hip Belt - 2 point non padded M L $80 74 MVSB05 BodyPoint Hip Belt - 2 point padded S M L $ MVSB06 BodyPoint Hip Belt - 4 point padded S M L $190 HEADREST 76 MVAC01 Profiled Headrest Small Medium Large $ MVAC02 Headrest mounting hardware with tension bar * $328 * Only available with push handles ACCESSORIES 78 MVAC03 Anti tippers $ MVAC04 Transit Tie Down - Unoccupied NC 80 MVAC06 Cane carrier Left Right $98 81 MVAC07 Oxygen tank holder Left Right $ MVAC08 Spoke guards* Available: 20", 22", 24", 26" WAMP $ MVAC09 Footrest neoprene impact guard (pr) - Black SEFND0035 $75 84 MVAC10 Seat pouch $95 85 MVAC11 Backpack $ MVAC12 Velcro Closing Strap $50 87 MVAC13 Tool kit $50 88 MVAC14 T-Shirt S M L XL XXL $28 * Not available with Mag wheels TOTAL NOTES T F November 19, of 7
5 CENTER OF GRAVITY Choose position of rear wheel axle plate: Measure distance from front of back post to center of axle receiver. Most stable Most responsive AMPUTEE 1 1/4" 2 1/4" Fork and Stem bolt combinations T F November 19, of 7
6 T F November 19, of 7
7 T F November 19, of 7
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
More informationMOVE 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 MOVE ORDER FORM - CANADA P.O. number:* Date:
More information4.2. 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
More information4.8. 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.
More information4.2 HELIO KIDS MODEL. Ultralight Folding Carbon Fiber HELIO KIDS Wheelchair Including angle & depth adjustable back (79 kg lbs weight capacity)
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
More information4.6. A7 FRONT Seat-to-floor Height - Please select your choice. Stem bolt Length /2 15 1/2 16 1/2
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 P.O. number:* Date: Ship to:* Company Name:*
More informationHelio 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:*
More informationHelio 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:*
More information4.8. Clinician/ATP/RTS: City: Prov: A7 FRONT Seat-to-floor Height - Please select your choice /2 15 1/2 16 1/2
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 A7 - FiveDay ORDER FORM - CANADA P.O.
More information4.8 MODEL WM / /2 15 1/2 16 1/ /2 15 1/2 16 1/ /2 16 1/2 17 1/2
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 C2 ORDER FORM - CANADA P.O. number:*
More informationHelio A7 - FiveDay 4.7. A7 FRONT Seat-to-floor Height - Please select your choice ORDER FORM - CANADA. P.O. number:* Date: Ship to:*
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 - FiveDay ORDER FORM - CANADA P.O.
More information4.6. 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:*
More information4.8. 3" caster 4" caster 5" caster /2 15 1/2 16 1/ /2 15 1/2 16 1/ /2 16 1/2 17 1/2
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 KIDS ORDER FORM - CANADA P.O. number:*
More information3 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.
More information4.8. 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.
More informationAPEX 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:*
More informationSTD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD
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:*
More informationC2 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.
More information4.8. 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:*
More information4.6. 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:*
More information4.8. 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:*
More informationVELOCE 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:*
More informationAPEX 4.7. FRONT Seat-to-floor height ORDER FORM - USA. Height available +- 1/4" Caster sizes. 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 APEX ORDER FORM - USA P.O. number:* Date: Ship to:* Company Name:*
More informationSling 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
Effective 05/07/2014 Company: Account Number: Date: q Quote q PO Number: RTS: Marked For: q Rogue XP 1825 Rogue Width Grow-able Frame. 275 lb weight capacity. Maximum initial : 16. q Rogue 1495 Rogue Standard
More informationMEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:
Canada MEDmobility 5711- Calgary Trail NW Edmonton AB T6H 2K1 P: 780-437-3300 F: 780-430-9381 www.medmobility.ca Company: Account Number: Date: Quote PO Number: RTS: AADL #W154 Effective 10/01/2017 Ship
More informationThis 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:
More informationq 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
More informationMASS 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
More informationFrame. Backrest. Seat Depth. Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time free growth kit. 165 lb weight capacity.
Canada Patent Pending AADL #W157 Effective 10/01/2017 Company: Ship To: Account Number: Date: Quote PO Number: RTS: Marked For: Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time
More informationMASS 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
More informationMASS 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
More informationInvacare 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
More informationq 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
More informationBENTLEY. 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
More informationFrame 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:
More informationFUZE 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
More informationq 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
More informationBENTLEY. 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
More informationSTELLAR. 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
More informationFUZE 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
More informationQuickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,
Quickie QXi AADL EIF6, October 2018 Mark For: Submitting for: Date: PO#: Quote Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City:
More informationBEARINGS 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....
More informationFUZE 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
More informationSTELLAR 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
More informationSTELLAR. 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
More informationFUZE 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
More information2241 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
More informationAccount 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
More informationAccount 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
More informationStandard 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
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