Please only send pages, that list your chosen products. equipment for a new wheelchair (-order/-enquiry) from. your pseudonymized reference:

Transcription

1 Please fill out this page completely. On the next page, please write the amount of the product requested in the appropriate area. your pseudonymized reference: The / enquiry is to be sent WITH this page with the number of sent pages (including this page) by to info@sorgrollstuhltechnik.de or by fax to I would like... an to s Please only send pages, that list your chosen products. equipment for a new wheelchair (-/-enquiry) from Orders of s receive a s discount (only exception are the positions of the side truss pads where the customized product discount applies). For s/enquiries to current new wheelchair s/enquiries, the agreed wheelchair discount applies. Without reference to an ongoing wheelchair, the s discount applies. This /enquiry has, including this page pages. address/ company stamp: wheelchair, the s discount applies. All prices plus tx / Price are valid starting / Technical changes and misprints reserved. PU=packing unit Please send by fax to page 1 of 7

2 point-pelvic belt size 1 with plastic fastener 2-point-pelvic belt size 2 with plastic fastener 2-point-pelvic belt size 3 with plastic fastener 2-point-pelvic belt size 1 with metal fastener 129,- 129,- 129,- 149, Orders of s receive a s discount. For an of a new wheelchair at the same time, the agreed wheelchair discount applies. / PU=packing unit Please write the amount of the product requested in the appropriate area, then chose the belt connection accordingly (lower and/or upper belt adapter, with choice of pipe clamps / buckles) on the pages to follow. 2-point-pelvic belt 4-point-pelvic belt 2-point-pelvic belt size 2 with metal fastener 2-point-pelvic belt size 3 with metal fastener size A B C D , , ,5 measurements in cm protection cap for metal fastener protection cap for metal fastener 14,- Fastening material for belts (to mount on frame) size A B C D E ,5 2, ,5 2, ,5 measurements in cm point pelvic belt size 1 with plastic fastener 4-point pelvic belt size 2 with plastic fastener 4-point pelvic belt size 3 with plastic fastener 4-point pelvic belt size 1 with metal fastener 4-point pelvic belt size 2 with metal fastener 4-point pelvic belt size 3 with metal fastener 159,- 159,- 159,- Easily slide the protection cap over the metal fastener and the lock can only be opened with a pin or the like. 149,- 149,- application example pipe clamps-set (2 clamps) plastic buckles size 1 (25mm) 4 pc. plastic buckles size 2 (40mm) 4 pc. set set set 10,- 14,- 17,- Please send /enquiry by fax to letzte last Änderung change am on Seite page 22 von of 7

3 chest-shoulder belt size 0 without zipper foot fixation with Velcro/fleece fastener and guide roller size 1 pair Orders of s receive a s discount. For an of a new wheelchair at the same time, the agreed wheelchair discount applies. / PU=packing unit Chest-shoulder belt Foot fixation chest-shoulder belt size 1 without zipper chest-shoulder belt size 2 without zipper chest-shoulder belt size 3 without zipper chest-shoulder belt size 4 without zipper L size A B C D E measurements in cm size foot fixation with Velcro/fleece fastener and guide roller size 2 foot fixation with Velcro/fleece fastener and guide roller size 4 length L cm cm cm pair pair Please send /enquiry by fax to page 3 of 7

4 Orders of s receive a s discount. For an of a new wheelchair at the same time, the agreed wheelchair discount applies. / PU=packing unit Upper belt holder for models Mio, Vector, Kika, Jump alpha, Jump beta, Tilty Vario, Tilty II and Mio Move To fasten chest-shoulder belts For a successful adaptation of the upper belt holder the following products must be on your wheelchair. Missing products can be easily ed here. For available head rest with square tube Square tube with 15x15mm adapter, completely black for upper belt connection incl. mounting material Square tube with 10x10mm adapter, completely black for upper belt connection at Lightweight head For available head rest with section tube Push handle/head rest holder 38mm straight, for mounting on stabilizing rod. incl. mounting material Without available head rest Holding rod for upper belt holder, 300mm length Push handle/head rest holder 38mm straight, for mounting on stabilizing rod. incl. mounting material Stabilizing rod (if not available) The push handle/head rest holder (650054) can be mounted on any SORG-stabilizing rod. For the of a stabilizing rod, we need the information of the serial nr. the seat width product product description M. X PU price/pu upper belt holder (recommended for sw 20-22) 140 mm upper belt holder (recommended for sw 24-30) 200 mm upper belt holder (recommended for sw 32-36) 260 mm upper belt holder (recommended for sw 38-42) 320 mm upper belt holder (recommended for sw 44-46) 380 mm At new wheelchair s the price is 90,- (Upper belt holder or ) 30,- 105,- upper belt holder. Please send /enquiry by fax to page 4 of 7

5 Orders of s receive a s discount. For an of a new wheelchair at the same time, the agreed wheelchair discount applies. / PU=packing unit Lower belt holder for Vector/Mio/Tilty Vario For the attachment of 2-point/4-point and/or chest-shoulder belts. Vector* *attachment on firm seat plate (not possible with a seat cover) Mio lower belt adapter (for SW 26-30) 260 mm lower belt adapter (for SW 32-36) 320 mm lower belt adapter (for SW 38-42) 380 mm lower belt adapter (for SW 44-48) 440 mm Tilty Vario lower belt adapter (for SW 18-22) 200 mm lower belt adapter (for SW 24-28) 260 mm lower belt adapter (for SW 30-34) 320 mm Lower belt adapter for model Kika For the attachment of 2-point/4-point and/or chest-shoulder belts. Kika lower belt adapter (for SW 28-30) 200 mm lower belt adapter (for SW 32-36) 260 mm lower belt adapter (for SW 38-42) 320 mm lower belt adapter (for SW 44-48) 360 mm lower belt adapter (recommended for SW 20-24) 210 mm lower belt adapter (recommended for SW 26-30) 270 mm Lower belt adapter for Mio Move For the attachment of 2-point/4-point and/or chest-shoulder belts. Mio Move lower belt holder. lower belt holder. lower belt adapter (recommended for SW 20-24) 190 mm lower belt adapter (recommended for SW 26-30) 250 mm lower belt adapter (recommended for SW SB 32-36) 310 mm lower belt holder. Please send /enquiry by fax to page 5 of 7

6 Orders of s receive a s discount. For an of a new wheelchair at the same time, the agreed wheelchair discount applies. / PU=packing unit Abduction wedge Not with a seat cover Side truss pads Image: truss pad holder size 2 Image: mounting abduction wedge size S 94x65x90 mm (L x W x H) incl. holder a. cushion abduction wedge size M 110x82x95 mm (L x W x H) incl. holder a. cushion abduction wedge size L 125x90x100 mm (L x W x H) incl. holder a. cushion holder for abduction wedge (without cushion) size 1 adjustable holder size 1 for left side (without cushion) up to max. 35kg adjustable holder size1 for right side (without cushion) up to max. 35kg additional extention joint (4,3 cm) for holder size 1 cushion incl. removable cover for holder size 1 (10 x 7 cm) cushion incl. removable cover for holder size 1 (10 x 9 cm) size 2 adjustable holder size 2 for left side (without cushion) from BH35 adjustable holder size 2 for right side (without cushion) from BH35 additional extention joint (5,5cm) for holder size 2 cushion incl. removable cover for holder size 2 (15 x 10) cushion incl. removable cover for holder size 2 (18 x 13) holder set to connect the side truss pads to the back holder set for Mio / Kika Image: truss pad holder size 1 sizes S, M and L For all positions of the side truss pads only the CUSTOMIZED PRODUCT DISCOUNT applies. holder set for Vector / Jump alpha / Jump beta / Tilty Vario / Mio Move 198,- 198,- 198,- 143,- Image: truss pad cushion 18x13 cm / 15x10 cm / 10x9 cm / 10x7 cm 60,- 60,- 40,- 40,- Please send /enquiry by fax to page 6 of 7

7 Orders of s receive a s discount. For an of a new wheelchair at the same time, the agreed wheelchair discount applies. / PU=packing unit Head rests Lightweight head rest for weight reduction Design curved lightweight Standard head rest light weight head size 1 rest for Mio, Mio Carbon and Mio Move (incl. height adjustable holder) light weight head size 2 rest for Mio, Mio Carbon and Mio Move (incl. height adjustable holder) rod holder head rest on stabilizing rod (square 15x15mm) 6400 Lightweight head rest for Mio, Mio Carbon and Mio Move Design Standard head rest model 1 Standard head rest model 2 shell shaped Design Standard head rest model 3 Standard head rest model 4 curved standard Design Standard head rest model 5 Standard head rest model 6 X-shaped height (y) width (x) depth 30 head rest model 1, shell-shaped small (incl. height adjustable holder) head rest model 2, shell-shaped large (incl. height adjustable holder) head rest model 3, curved small (incl. height adjustable holder) head rest model 4, curved large (incl. height adjustable holder) head rest model 5, X-shaped small (incl. height adjustable holder) head rest model 6, X-shaped large (incl. height adjustable holder) Please chose (if not available) a stabilizing rod by indicating the serial number and seat width of the wheelchair serial number: seat width: measurements in mm, all measures ± 10mm size 1 size 2 x y stabilizing rod (size depends on serial number + seat width) Lightweight head rest, adjustable with two conical joints, connection and removable cover included. (with new wheelchair, the breathable head rest cover will be delivered in same Betex-color as back cushion). Weight reduction approximately g to other head rest systems. Only possible with stabilizer bar. Betex-colors: grey red yellow green orange black blue 286,- 286,- 60,- 105,- Please send /enquiry by fax to page 7 of 7