Top End Crossfire T7A Ultra Lightweight AADL Customers Only Active Performance Adjustable Rigid Wheelchair AADL # W149
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1 Top End Crossfire T7A Ultra Lightweight AADL Customers Only Active Performance Adjustable Rigid Wheelchair AADL # W149 Suggested Canadian Price List Effective October 1 st, 2018 For accuracy of ordering, please fax order to Invacare Canada or Toll Provider Name Date Top End Job Number Account # P.O. # Phone # Fax # Address City Prov. Postal Code Customer Name Phone No Address City Prov. Postal Code Ship order to: Provider Customer Order will ship to Provider unless otherwise noted. FRAME TYPE: CT7A Crossfire T7A... 3, FRONT FRAME MODIFICATONS: (CHOOSE ONE) TFE Tapered Front End... No Charge 2 CRF2 Non Tapered "V" Front End FRONT SEAT-TO-FLOOR HEIGHT: 2 FSTF 16" 16.5" 17" 17.5" 18" 18.5" 19" 19.5" 20" 20.5" 21" 7 FORK OPTIONS: FLOSF Frog Legs One-Sided Fork SEAT WIDTH: 4 W12 W13 W14 W15 W16 W17 W18 W19 No Charge W SEAT DEPTH: 5 6 D14 D15 D16 D17 D18 D19... No Charge D Width and Depth Matrix 12W 13W 14W 15W 16W 17W 18W 19W 20W 14D A A A A A A A S S 15D S S A A A A A S S 16D S S A A A A A A A 17D S S A A A A A A A 18D S S A A A A A A A 19D S S S S A A A A A 20D S S S S S S A A A S = Special, A = Available REAR SEAT-TO-FLOOR HEIGHT: 8 RSTF 14" 14.5" 15" 15.5" 16" 16.5" 17" 17.5" 18" 18.5" 19" 19.5" 20" FRONT FRAME ANGLE: FFA70 FFA75 FFA80 FFA85 CENTER OF GRAVITY:9 COGAC Active Position... Standard COG POSITION 10 : (CHOOSE ONE) COG075 COG125 COG175 COG225 COG275 COG325 COG No Charge No Charge Standard No Charge No Charge No Charge No Charge 1 Crossfire T7A is built of 7005 Aluminum. 2 Tapered front end not available with front seat heights of 16" through Not available w/tapered seat width or tubular footrest. 4 W12 & W13 only available with D14 or Less, W14 & W15 not available with D19 or D20, W16 not available with D20, W19 and W20 not available with D14 or D Seat Depth only available with Front Seat To Floor Height less than Seat Depth only available with Front Seat To Floor Height less than " front seat-to-floor height is not available with a 16" seat depth. 8 14" is the lowest rear seat height for 22" wheels, 15" for 24" wheels with std. tires, 15.5" for 25" wheels with std. tires or 24" wheels with knobby tires, 16" for 25" wheels with knobby tires or 26" wheels with std. tires. 9 The nominal (i.e, zero) position are back canes perpendicular with the ground. 10 Measured from the front of the back post to the center of the axle. For most up to date price lists please visit Page 1 of 5
2 Overall Width by Camber Angle Wheel Type Spoke 6.75" 8" 10" 12.25" Add the amount above to the seat width to obtain the overall width at its widest point. 116P 117 Sunkissed Orange.... No Charge Tangerine Red......No Charge ANODIZING ACCENTS ANOBLK ANOSLV Bold Black... Standard Classic Silver... No Charge ANOBLU Shadow Blue ANORED Victory Red WHEELS CASTER OPTIONS: 3SOFR 3" Aluminum Soft Roll CRFF3 3" Micro... No Charge 41DC 4" Urethane... No Charge 51DC 5" Urethane... No Charge CRF654 4" Semi-Pneumatic... No Charge CRF655 5" Semi-Pneumatic... No Charge CRFA654 4" Aluminum Soft Roll CRFA655 5" Aluminum Soft Roll CRF884 4" Lighted Front Wheels CAMBER SYSTEM 14 CRF630 0 Camber Tube with Single Camber... Standard CRF633 3 Camber Tube with Single Camber... No Charge CRF636 6 Camber Tube with Single Camber... No Charge CRF640 0 Extra Camber Tube CRF643 3 Extra Camber Tube CRF646 6 Extra Camber Tube FRAME COLORS 24P 60P 115P 105P 30P 61P 119P 120P 62P 127P 29P Wet Black... No Charge Silver Metallic... No Charge Black Prism... No Charge Midnight Blue... No Charge Sunny Yellow... No Charge Electric Red... No Charge Bubblegum Pink... No Charge Grape Madness... No Charge Electric Blue... No Charge Grasshopper Green... No Charge White Snow...No Charge REAR WHEEL OPTIONS: (SEE WHEEL/TIRE CHART) 22ITESPK 22" Light Weight Perf. Stylized Spoke... No Charge 15 24ITESPK 24" Light Weight Perf. Stylized Spoke... No Charge 25ITESPK 25" Light Weight Perf. Stylized Spoke... No Charge 26ITESPK 26" Light Weight Perf. Stylized Spoke... No Charge CRF " Spinergy Spox Wheels CRF " Spinergy Spox Wheels CRF " Spinergy Spox Wheels CRF " Spinergy Spox Wheels SPLX24 24" Spinergy LX Wheels SPLX25 25" Spinergy LX Wheels FN " Sun Fusion 16 Spoke Wheel FN " Sun Fusion 16 Spoke Wheel FN " Sun Fusion 16 Spoke Wheel Includes Forks, Seat Slope Crescent Pivot Link, and Back Angle Bracket 12 Anodizing accents are not exact matches to any frame colors. Shadow Blue does not match any blue frame, Victory Red does not match the Electric Red frame, and Classic Silver does not match the Silver Metallic frame. 13 Aluminum soft roll casters are 1.4" wide with soft roll tires. For suspension fork option, see page , 3, and 6 degree camber with 22" wheels not available with 19.5" through 21" front seat heights 15 22" wheels not available with 19", 19.5", 20", 20.5" and 21" rear seat heights. 16 FN1624 excludes CRF73; FN1625 excludes CRFPN and CRF73; FN1626 excludes CRF73, CRF60, CRF7G, CRF7BK, CRF101R and CRF101Y; CRF6722 excludes CRF123, CRF60, CRF7G, CRF7BK, CRF101R and CRF101Y; CRF6724 and SPLX24 excludes CRF73; CRF6725 and SPLX25 excludes CRFPN and CRF73; CRF6726 excludes CRF73, CRF60, CRF7G, CRF7BK, CRF101R and CRF101Y For most up to date price lists please visit Page 2 of 5
3 *Spinergy Spoke Color (If color is not chosen, spokes will be black) SPCY Yellow SPCBK Black SPCW White SPCR Red SPCBL Blue TIRE OPTIONS: (SEE WHEEL/TIRE CHART) CRFPR Primo High Pressure Tires: Grey... No Charge CRFPN Pneumatic 1 3/8 Treaded: Grey... No Charge CRF123 Schwalbe 1" Flat resistant: black CRF73 Pneu w/ff 22 or 24 x 1 3/8" Tires CRF60 Knobby Tires Grey CRF7G Solid No Flat Tires: Grey CRF7BK Solid No Flat Tires: Black CRF101R Kenda High Pressure Tires: Red CRF101Y Kenda High Pressure Tires: Yellow HANDRIM OPTIONS: BLKANHR Bold Black Anodized Handrims... Standard CRF77 Aluminum Anodized Handrims... No Charge CRF75 Titanium Handrims CRF8 Coated Handrims CRF99 Natural Fit Standard Grip Handrims CRF98 Natural Fit Super Grip Handrims NFSDLT Natural Fit LT Standard Grip Handrims NFSPLT Natural Fit LT Super Grip Handrims MOUNTING HANDRIMS: OUT IN AXLE TYPE: Mount Outside Handrim... Standard Mount Inside Handrim (Close)... No Charge A1577 Quick Release Axles... Standard CRF27 Quad Release Axles CRF76 Titanium Axles WHEELS: EXTRA SET FOR OFF ROAD (INCLUDES: WHEELS, TIRES & ALUMINUM PUSHRIMS) CRF91 24" Knobby Tires (540) CRF92 25" Knobby Tires (559) CRF93 Extra Set of Axles (quick release) WHEEL LOCKS (CHOOSE ONE) CRFPUL Pull to Lock Wheel Locks... No Charge CRFPSH Push to Lock Wheel Locks... No Charge CRF109 Hideaway Undermount Wheel Locks CRF22 Hill Holders CRFOWL Omit Wheel Locks... No Charge POSITIONING BACK TYPE: 21 LKDWN Lock-Down, Folding Ht/Angle Adj Back... Standard BACK HEIGHT: (CHOOSE ONE) 21 BH811 8" 11" BH " 14" BH " 16" BH " 18" BH " 20" 17 Natural-Fit handrims not available with 22" std. spoke wheel " knobby match up with 25" daily use wheels, with Primo tires and 25" knobby match up best with 26". Extra set includes standard wheels, anodized handrims and knobby tires. 19 Not available on 14" depth. 20 Not available with urethane tires (CRF7G/CRF7BK) 21 16º range in 4 increments (98, 94, 90, 86, 82); factory setting ~90 relative to ground. The folding back is manufactured of 1" aluminum tubing and is available with adjustable height (3/4" tube telescoping in 1" tube). BACK UPHOLSTERY OPTIONS 22 CRFBAT Ballistic Nylon Adj. Tnsn Uph w/ Anchors... Standard MESH Breathable Mesh Adj. Tnsn Uph w/anchors. No Charge CRF16 Fold Over Back Upholstery BACK UPHOLSTERY COLORS (BLACK STANDARD) UPH1 Woodland Camouflage SEAT UPHOLSTERY: CRFTI112 Screw-on Seat Upholstery... Standard CUSHION 24 CRF14 2 Soft Cushion ARM TYPE CRF78 Swingaway Arms... Standard 25 TAHD T Arm Adj Hgt Desk MISCELLANEOUS BACK ACCESSORIES: CRF82 Push Handles adjustable height bolt-on CRF13 Push Handles non-adjustable bolt-on CRF97 Bolt-through Integral Push Handles L8601 Omit Back Upholstery... Less NET SEAT ACCESSORIES: CRF29 Seat Pouch CRF72 Positioning Strap Hook & Loop CRF74 Positioning Strap Auto Style ARM ACCESSORIES (SIDE GUARDS) CRF121 Fold-in Style Black Aluminum Side Guards CRFSG Fold-in Style Carbon Fiber Side Guards CRF79 Removable Side Guards/Fender CRF18 Rigid, Removable Side Guards w/hole CRF19 Rigid, Removable Side Guards w/o hole MISCELLANEOUS ACCESSORIES CRF21C Spoke Protectors: Clear CRF23 Rear Anti Tippers CRF94 Alignment Gauge WLEXT 6 IN Wheel Lock Extensions.,.,63.00 FOOTPLATE OPTIONS: CRFTFR 1 Piece Tubular Footrest... Standard 30 CRF1FP Adjustable Angle One Pc Ftplate... No Charge 31 CRF191 Adjustable Angle Footrest with 2" Risers All back upholstery options are a standard black color. CRF16 is Nylon ONLY 23 Camouflage upholstery available with CRFBAT and CRF16 24 Cushions are soft foam cushions not intended to provide skin protection or positioning. If a therapeutic cushion is needed please order from Invacare Customer Service Adjustable height push handles are not compatible with swingaway arms. The non-adjustable push handles (CRF13) or integral style will work. 26 Not available w/side guard options; comes standard with rigid side guards. 27 Bolted to the back post and have 10" of adjustment up or down. 16" tall. Adjustable height push handles are not compatible with swingaway arms. The non-adjustable push handles (CRF13) or integral style will work. 28 Not available with fold over back upholstery (CRF16). 29 Fold-in Style SG: Fold-in style flip back for easier transfers and are adjustable in height. Compatible with both high (push or pull to lock) or undermount (scissor) wheel locks. Not available with adjustable height push handles if back height is 10-14" or less. 30 One piece tubular footrest does not have a cover. 31 Adjustable angle one-piece footplate is standard for frames with V style front end and not available with CRFTFR For most up to date price lists please visit Page 3 of 5
4 FOOTREST/LEGREST ACCESSORIES: CRF10 Plastic Footrest Cover CRF89 Carbon Fiber Footrest Cover FRMPRBK ChairArmor Black Neoprene Frame Protectors.No Charge FRMPRB ChairArmor Blue Neoprene Frame Protectors FRMPRR ChairArmor Red Neoprene Frame Protectors CRF103 Luggage Carriers CRF133 Calf Strap... No Charge FOOT SPACE WIDTH: = standard as per diagram above. Exception: seat widths of 12", 13", and 14" will have foot space width of 8". 32 Tubular footrest only. 33 Set of 3 pieces includes two front frame protectors and one rigidizer bar protector For most up to date price lists please visit Page 4 of 5
5 Invacare Crossfire T7A Peak-Performance Rigid Wheelchair Accessories and Options Invacare Canada LP HEAD OFFICE All rights reserved. Trademarks are identified by the symbols and. All 570 Matheson Blvd, trademarks are owned by or licensed to Invacare Corporation unless otherwise noted. Unit #8, Products designated by ASL are Manufactured by Adaptive Switch Labs, Inc. Mississauga, ON Sun is a registered trademark of Sun Components Inc. L4Z 4G4 Spinergy is a registered trademark of Spinergy Corp. Phone: (905) Schwalbe is a registered trademark of RALF BOHLE GmbH in Reichshof Germany. (800) Frog Legs is a registered trademark of Frog Legs, Inc. Fax: (905) Kenda is a registered trademark of Kenda Rubber Industrial Co. Ltd. (800) Specifications and prices are subject to change without notification Invacare Corporation Form No C Rev 10/01/2018 Page 5 of 5
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Invacare MyOn Active HD Folding Wheelchair AADL Customers Only AADL # W155 Effective October 1, 2018 NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS FRAME SELECTION FRAME TYPE MYONAC MyOn Active Folding Wheelchair
MEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:
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FRAME SELECTION FRAME TYPE Seat angle is set at 3 degrees. See service manual for details. PATRIOT Folding Frame w/swingaway Front End $1,345 FRAME WIDTH W14 14'' Wide No Charge Not available with 18"
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
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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
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
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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 : PO : Vendor : CUSTOM TECHNOLOGIES LIMITED Date
This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.
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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
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
Parts Catalog Issued: Mar 12, Comet Rocket. Wheelchairs
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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
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Zippie Zone July 2018 EIRZ1
Zippie Zone July 2018 EIRZ1 Date: SUBMITTING F: Quote Order Dealer Acct #: Dealer: PO#: Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: PV: PC: Address: Dealer Phone: ( ) Fax: ( ) Address:
Transformer. Rev C. Aug 15, 2010 Page 1 of 8
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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
Serial Number: Manufacturing Date: /20
Sunrise Medical Head Office: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: +1.800.263.3390 Fax:+1.800.561.5834 csrcanada@sunmed.com www.sunrise.ca Distributor Name: Dealers Name: Contact
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: 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:*
Quickie GTX Fixed Frame EIF3, Effective July 2009
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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:*
Quickie Q7 Adjustable March 2014
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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
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
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:*
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:
Serial Number: Manufacturing Date: /20
Sunrise Medical Head Office: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: +1.800.263.3390 Fax:+1.800.561.5834 csrcanada@sunmed.com www.sunrise.ca Distributor Name: Dealers Name: Contact
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.
MVP / MVP jr. (After 10/15/01) Xtra (After 8/31/04)
Parts Catalog Issued: Apr 9, 2019 MVP / MVP jr. (After 10/15/01) Xtra (After 8/31/04) Wheelchair Parts Catalog Usage Guide The information contained in this document is subject to change without notice.
RETAIL Max user weight: 100kg - seat widths 12" & 13" Max user weight: 130kg -seat widths 14" -16"
Manual Wheelchair Retail Prescription Form ACTION515112017 Tel: 01656 776222 Fax: 01656 776220 JAN 2018 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer Ref: Contact
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:*
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
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
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:*
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 C H U M P - G 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:
TiLite. Please Fax to the TiLite Customer Service Team at or
- Print as guide for ordering DEALER INFORMATION ler: Adaptive Specialties RTS INFORMATION RTS: Email: SHIP TO INFORMATION Phone: Page 1 of 9 Email: TiLite Information Name: Ship Via: : Please Fax to the
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
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.
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
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
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:*
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.
NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS
Invacare 9000 XT Wheelchair Suggested Canadian Price List Effective January 2nd, 2018 NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS Pre-Configured Stock Models Stock Chairs 9XT_PTO_29153 9XT/WD86/88-9000XT
Voyager Evo. Rigid-frame active wheelchair. Standard equipment. Canada: Fax: Order Form and Price List
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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. 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:*
4.6. 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:*
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
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:
NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS
Print Form Save Form Submit Form Clear Form Contents Invacare TDX SP Rehab Seat Power Wheelchair Suggested Canadian Price List Effective July 25, 2017 NAME PHONE NO ACCOUNT # P.O. DATE ADDRESS BASE CHAIR
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:
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Manual Wheelchair Retail Prescription Form UltraLight061216 Tel: 01656776222 Fax: 01656776220 Email: ordersuk@invacare.com JANUARY 2017 Online spares available at: www.invacare.co.uk Account No : Built
YOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP.
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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 S PA Z Z - G 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:
Condor Script Form Folding Frame Day Wheelchair 90050
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Quickie QX December 2018
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Quickie QX July 2017
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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:*
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
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.
Custom Manual Options & ACCESSORIES AUSTRALIA 2013
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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.
RGK Tiga Sub4. July Serial Number: Manufacturing Date:
Manufacturing Date: Sunrise Medical Head O ce: 237 Romina Drive, Unit 3 Concord, ON L4K 4V3, Canada Telephone: +1.800.263.3390 Fax:+1.800.561.5834 E-Mail: cscanada@sunmed.com www.sunrisemedical.ca RGK
2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) Freedom 2 Kids
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SEATING CHOICE TITANIUM FRONT FRAME
Manual Wheelchair Retail Prescription Form Champion140618 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk July 2018 Account No : Contact
This wheelchair has a weight limit of 80kg
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Page 1 of 7 DEALER INFORMATION RTS INFORMATION Dealer: RTS: Phone: Account: PO: Email: Ordered By: SHIP TO INFORMATION Address: Name: Ship Via: City: State: Zip: Address: Phone: Fax: City: State: Zip:
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:*
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:*
Quickie 2 EIQ2N Effective April 2011
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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 MOVE ORDER FORM - CANADA P.O. number:* Date:
Order Date : carbon. Tension adjustable seat, option DDA0611 is not possible with seat width 320mm
Manual Wheelchair Retail Prescription Form KSeriesCarbon061218 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk January 2019 Customer Ref:
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Manual Wheelchair Retail Prescription Form Champion161116 Tel: 01656776222 Fax: 01656776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk JANUARY 2017 Account No : Built in
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Quickie 2 January 2014
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BEARINGS BEARINGS
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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.
Quickie 2 AADL - W137
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