4.1 MOVE. ORDER FORM - CANADA Ship to: Name: Address: Account: Vendor: Date: Ordered by: Marked for: User manual: PO: Postal Code: Phone:
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1 519, J-Oswald Forest, suite 101 Saint-Roch-de-l'Achigan, QC, Canada J0K 3H0 T F Account: Vendor: Date: Ordered by: Marked for: User manual: English PO: Français 4.1 MOVE ORDER FORM - CANADA Ship to: Name: Address: City: Postal Code: Phone: Province: MODEL 1 Ultralight MOVE wheelchair aluminum. Basalt Black (250 lbs. weight capacity) WM $ Heavy duty kit (350 lbs. weight capacity) WAMF $740 FRAME COLOR (with black aluminum crossbrace) 3 Basalt Black STD 4 Sunkissed Orange Burgundy Saphir Blue Monster Green $270 Charcoal Fushia Steel Blue Ferrari Red Acid Green 5 Custom Color $400 SEAT WIDTH 6 Seat width: 14" 16" 18" 1 7 Seat width: 20" 1 22" 2 WAMA $285 SEAT DEPTH 8 Seat depth: 16" 18" 9 Seat depth: 20" WAMB $215 1: Available with HD kit 2: Only available with HD kit 8 BEND BACK (with fixed height push handles) 10 Aluminum back cane 16" 20" 8 BEND ADJUSTABLE ANGLE BACK (with fixed height push handles) 11 Aluminum back cane 16" 20" $ Select back cane angle: PUSH HANDLES OPTIONS 13 Stroller handle WAMW $ Folding Stabilizer bar $250 T F April 01, of 5
2 SEATING CUSHION 15 2" Cushion $ " Cushion $ nxt FIT cushion series (See nxt FIT pricelist) See pricelist BACK UPHOLSTERY 18 Slip on back upholstery 19 Adjustable tension back upholstery WAMD/WAME $ Omit back upholstery RIGID BACK 21 nxt back series (See nxt back pricelist) See pricelist FLIP BACK ARMREST (Convertible to T" armrest) Height Adjustment 22 Desk Length 8-12" 10-14" $ Full Length 8-12" 10-14" $370 T" ARMREST Height Adjustment 24 Desk Length 8-12" 10-14" $ Full Length 8-12" 10-14" $350 SWING-AWAY FOOTREST Set Length to: swing away footrest, Length adjustable $ swing away footrest, Length adjustable $ Elevating legrest with calf pad, Length adjustable Left Right WAMK $ Length modification, less than 14 or over 18 $90 STUMP SUPPORT (Height and angle adjustable) 30 Swing away stump support: 8" x 11" Left Right SEFND0005 $375 FOOTPLATES 31 Standard (Composites) STD 32 Adjustable angle (Aluminum) WAMJ $ Length adjustable heel loop 34 Calf strap $50 35 Padded calf strap $80 T F April 01, of 5
3 CASTERS 36 Composite wheel w/ PU tire (1" width) 4" 5" 6" 7" 8" 37 Pneumatic 6" x 1 ¼" 8" x 1 ¼" $160 FROG LEGS CASTERS 38 4" x 1 ½ " $ Composite wheel Soft-Roll by Frog Legs 1 5" x 1 ½ " $ " x 1 ½ " $ " x 1 ½ " $ Aluminum wheel Soft-Roll by Frog Legs 1 5" x 1 ½ " $ " 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* 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 * Config = Stem bolt & Fork 5" caster Config* 6" caster Config* 7" caster Config* 8" caster 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 44 Mag 20" 22" 24" 45 Newton One - spoke wheel 22" 24" 46 Newton Gravity - ultralight wheel 20" 22" 24" 25" 26" $350 TIRES 47 Soft Urethane 1 3/8 " 20" 22" 24" STD 48 Soft Urethane knoby 1 3/8 " 24" $ Soft Urethane - Shox 1" 24" 25" $ Pneumatic 1 3/8 " 20" 22" 24" 25" 26" $ Pneumatic HP - Schwalbe Right Run 1" 20" 22" 24" 25" 26" $ Pneumatic HP - Schwalbe Marathon Plus 1'' 24" 25" 26" $190 20" 22" 24" 12 1/4" 13" 14" 13 1/4" 14 1/4" 15 1/4" 16 1/4" FRONT Seat-to-floor Height - Please circle your choice & 7" P5 REAR Seat-to-floor Height +/- 1/4" - Please circle your choice 14" 15" 16" 14 1/4" 15" 15 1/4" 16" 16 1/4" 17 1/4" 18" 18 1/4" 19" 17 1/4" 18" 19" 19 1/4" 20" 25" 26" 15" 16" 18" Config* T F April 01, of 5
4 HANDRIM Assembly Available 53 Aluminum anodized 20", 22", 24", 25", 26" STD regular 54 Plastic coated 20", 22", 24", 25", 26" WAMO $150 narrow* 55 Q-Grip High friction plastic coated* 22", 24", 26" WAMO $ Natural Fit- Standard grip* (oval aluminum handrim w/thumb piece) 22", 24", 26" $370 Surge LT handrim* regular 57 (oval aluminum handrim w/ a rubber high friction strip) narrow* 22", 24" $ Omit handrim * Not available with Mag wheels AXLE (0 camber) 59 Quick release axle WAMU STD 60 Permanent axle 61 Quad release axle WAMU $ Amputee adjustable axle plate (may interfere with swing away armrest) WAMT $240 WHEEL LOCK 63 Push to lock STD 64 Pull to lock 65 6" removable extension handle $65 66 Newton Grade aid push to lock (suggested with pneumatic or high pressure tire) WAMR $ Attendant Lock (additional set of wheel lock mounted to the back) $220 POSITIONING BELT (2 points seatbelt attachment hardware is included with the MOVE) 68 Velcro adjustable $40 69 Auto buckle $50 70 Additional attachment hardware for 4 point seatbelt $12 71 BodyPoint Hip Belt - 2 points non padded M L $80 72 BodyPoint Hip Belt - 2 points padded S M L $ BodyPoint Hip Belt - 4 points padded M L $190 ACCESSORIES 74 Anti tippers $ Unoccupied transit tie down 76 Cane carrier Left Right $98 77 Spoke guards* Available: 20", 22", 24", 26" WAMP $ Footrest neoprene impact guard $75 79 Seat pouch $95 80 Backpack $95 81 Velcro Closing Strap $50 82 Helio T-Shirt S M L XL XXL $25 * Not available with Mag wheels TOTAL NOTES T F April 01, of 5
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 11/4" 21/4" Fork and Stem bolt combinations T F April 01, of 5
4.2. Ship to: Vendor: Name: Date: Address: Ordered by: 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 orders@motioncomposites.com www.motioncomposites.com 4.2 MOVE ORDER FORM - CANADA
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
4.2 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
MOVE 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:
4.6. 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:*
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:*
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:*
4.8. 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.
4.8 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:*
Helio 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.
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.
4.8. 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:*
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:*
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.
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.
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.
STD +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:*
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:*
4.8. 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:*
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:*
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:*
APEX 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:*
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:*
MEDmobility 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
Sling 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
This 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:
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
Frame. 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
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
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
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
q 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
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
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:
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 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
Quickie 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:
q 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
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
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
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
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....
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
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
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
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
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
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:
Condor Script Form Folding Frame Day Wheelchair 90050
90050 To Order Fill in the frame dimensions and features required. For variations describe in detail on a separate page. If you have any further questions contact us at the address at the bottom of the
Condor Script Form Folding Frame Day Wheelchair 90050
90050 To Order Fill in the frame dimensions and features required. For variations describe in detail on a separate page. If you have any further questions contact us at the address at the bottom of the
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
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:
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
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
Stallion Script Form Fixed Frame Adjustable Wheelchair 90100
90100 To Order Fill in the frame dimensions and features required. For variations describe in detail on a separate page. If you have any further questions contact us at the address at the bottom of the
Additional Front Wheel Options Not Shown FW1 3 x.75 Micro-Caster FW14 4 x.75 Plastic Wheel w/poly Tire FW3 4 x.75 Light-Up Micro-Caster
front wheels FW2 3 x.75 Light-Up Micro-Caster FW23 3 x1.5 Billet Aluminum Micro Caster w/soft Roll Tire FW19 4 x.75 Performance 5 Spoke Billet Aluminum Wheel w/poly Tire - Silver Hub OR Black Hub FW20
SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5
PARTS CATALOG CONTENTS SIDEFRAME AND CROSSBRACE... ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5 FRONT RIGGING, DETACHABLE... 6 UPHOLSTERY... 7 ACCESSORIES...
Account Number: Provider Name: Contact:
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