Transformer. Rev C. Aug 15, 2010 Page 1 of 8
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1 Transformer Rev C. Aug 15, 010 Page 1 of 8
2 Rev C. Aug 15, 010 Page of 8
3 ITEM PART NUMBER PER CHAIR DESCRIPTION Upper Seat Frame, specs required - send new complete chair order form Lower Frame, right, specs required - send new complete chair order form Lower Frame, Left, specs required - send new complete chair order form Backrest Crossmember Asm (specify seat width) Clamp Asm, Rear Frame, TRFM Right Clamp Asm, Rear Frame, TRFM Left Clamp Asm, Front Frame, TRFM Camber Tube w/ Single Camber (see page 4 for Camber Tube specs) Axle Receiver, Lock Washer, Washer, Nut Assembly (Sport) Clamp Asm, Camber Tube, Right Clamp Asm, Camber Tube, Left Anti-Tip Bracket Kit (includes brackets, 4 screws) Anti-Tip, Single Swivel (specify rear wheel size, camber, seat width) Cap, Head Tube Bearing, Headtube, 1-1/8"OD, 1/"ID, 5/16"Thick Adjustable Height Head Tube, Anti-Tip " Fork Assembly (includes fork, stem, and locknuts) " Caster w/ Composite Hub (Bearings included) 3" Lighted Caster w/ Composite Hub (Bearings included) Caster Mounting Hardware Kit Adjustable Angle One Piece Footplate (specify footrest width) Clamp, Raised Footrest, 1" to 3/4" Adaptive Footplate Spacer Kit (spacers & screws), (circle one) " 4" 6" QTY Toe Clip Kit (pair) Double Anti-tip Assembly (specify rear wheel size, camber, seat width) Full Wing (specify seat width, seat depth, camber) Bumper (specify seat width) Adjustable Back Upholstery (specify back height, seat width) RH Back (Adjustor) (specify back height, seat width) LH Back (Anchor) (specify back height, seat width) Back Center (specify back height, seat width) Seat Upholstery, Adjustable Tension (specify seat width, seat depth) Fold Over Back Upholstery (specify back height, seat width) Soft Cushion (circle one) " 3" 4", also specify seat width, seat depth Hard Cushion (circle one) " 3" 4", also specify seat width, seat depth Screw-on Seat Upholstery Complete Folding Back Assembly (specify seat width and back height) Folding Back, Frame Only (specify seat width and back height) Folding Back Latch Kit (includes both RH & LH) Seat Width: Seat Depth: Back Height: Wheel Size: Camber: Footrest Width: Rev C. Aug 15, 010 Page 3 of 8
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6 ITEM PART NUMBER WHEELS " (501) Performance Rear Wheel: Radial " (540) Performance Rear Wheel: Radial " (540) Performance Rear Wheel: Crossed " (540) Spinergy Sport Wide Hub (Yellow or Black) " (559) Performance Rear Wheel: Radial " (559) Performance Rear Wheel: Crossed " (559) Spinergy Sport Wide Hub(Yellow or Black) " (590) Performance Rear Wheel: Radial " (590) Performance Rear Wheel: Crossed " (590) Spinergy Sport Wide Hub (Yellow or Black) " (700c) Performance Rear Wheel: Indicate Radial or Crossed Spokes " (700c) Spinergy Sport Wide Hub (Yellow or Black) Bearing, Rear Wheel 1-1/8" OD, 1/" ID, 5/16" Width HANDRIMS " Anodized Handrim " Vinyl Coated Handrim - Black " Anodized Handrim " Vinyl Coated Handrim - Black " Titanium Handrim " Anodized Handrim " Vinyl Coated Handrim - Black " Titanium Handrim " Anodized Handrim " Vinyl Coated Handrim - Black " Titanium Handrim " (700c) Anodized Handrim Handrim Hardware Kit (6) 10-3 x 1/" Screws, (6) 10-3 Locknuts TIRES AND TUBES PER CHAIR " (501) Primo V Track High Pressure Clincher Tire " (501) Tube (Presta Valve) 4" (540) Primo V Track High Pressure Clincher tire 4" (540) Kenda Sport Tire, Clincher, Red 4" (540) Kenda Sport Tire, Clincher, Yellow 4" (540) Tube (Presta Valve) 5" (559) Primo V Track High Pressure Clincher tire 5" (559) Kenda Sport Tire, Clincher, Red 5" (559) Kenda Sport Tire, Clincher, Yellow 5" (559) Tube (Presta Valve) 6" (5-590) Primo High Pressure Clincher Tire 6" (590) Kenda Sport Tire, Clincher, Red " (590) Kenda Sport Tire, Clincher, Yellow " (590) Tube (Presta Valve) " (700c) Primo High Pressure Clincher Tire " (700c) Tube (Presta Valve) Rim Strip (circle one ) ", 4", 5", 6", and 700C OTHER " Spoke Guards, specify clear or black and wheel size 5" Spoke Guards, specify clear or black and wheel size 6" Spoke Guards, specify clear or black and wheel size DESCRIPTION QTY. Rev C. Aug 15, 010 Page 6 of 8
7 Rev C. Aug 15, 010 Page 7 of 8
8 ITEM Rear Back Bar Frame Protector (each) Front Frame Vertical Protectors (pair) Leg / Calf Strap, for Foot Widths: 8-10" (36") 10 1/" - 13" (41") 13 1/"+ (46") Positioning strap, Velcro hook & loop style Seat Positioning Strap, Auto Style Buckle Hideaway Undermount Wheellock Hideaway Undermount Wheellock Wheel Lock, Push/Pull to Lock Assembly, Right Wheel Lock, Push/Pull to Lock Assembly, Left Clamp Assembly, Wheel Lock Removable Side Guard, Large, Right Removable Side Guard, Large, Left Removable Side Guard, Small, Right Removable Side Guard, Small, Left Mounting Hardware Kit for Removable Side Guards Metal Spoke w/ Nipple (indicate model, crossed/radial, and wheel size) 19 PART NUMBER PER CHAIR Spinergy Spox Spoke (3mm) Spinergy LX/SLX Spoke (4mm) Wheel Size: 4" 5" 6" 700c Wheel Size: 4" 5" 6" 700c DESCRIPTION Presta Valve Adaptor Axle, Quick Release, Standard Axle, Quick Release, Standard, for Wide Hub Axle, Quick Release, Titanium Axle, Quick Release, Titanium, for Wide Hub Axle, Quad Release, Standard Clamp-On Side Guard, includes: (1) panel, (3) clamps w/ hardware Alignment Gauge Fold-In Side Guard Panel w/ Pivot Bracket, Right Large Small Fold-In Side Guard Panel w/ Pivot Bracket, Left Large Small Seat Clamps for Fold-In Side Guards (for use on 1" Frame Tubing) Click Strap Set, 8" Pad Length (Small) Click Strap Set, 10" Pad Length (Medium) Click Strap Set, 1" Pad Length (Large) Yellow Black White Red Blue Yellow Black White Red Blue Wide Hub Hub Wide Hub Hub Narrow Narrow QTY. Rev C. Aug 15, 010 Page 8 of 8
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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
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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
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4.2. Ship to: Vendor: Name: Date: Address: Ordered by: City: Province:
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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...
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Serial Number: Manufacturing Date: /20
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Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription form Pencoed. CF35 5AQ LPF1U2CHAMPION011113D Tel: 01656 776222 Fax: 01656 776220 LPF0015X email: ordersuk@invacare.com January
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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:
Account Number: Provider Name: Contact:
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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 4.6 APEX ORDER FORM - International P.O. number:*
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Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed LPF1U2KSERIES021213D CF35 5AQ LPF0019X Tel: 01656 776222 Fax: 01656 776220 January 2014 email: ordersuk@invacare.com
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Order Form. English Company stamp. Version mudguard (AVAILABLE ONLY WITH REAR WHEELS 24'') Version straight sideguard
NONO Date User name Company stamp Rigid frame wheelchair Responsible Wheelchair measures Seat width (LS) 33 36 39 42 45 48 The seat width is measured from the outer sides of the frame, while the distance
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
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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:*
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Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription form Pencoed. CF35 5AQ LPF1U2CHAMPION240513D Tel: 01656 776222 Fax: 01656 776220 LPF0015W email: ordersuk@invacare.com July 2013
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: FOOTREST, DETACHABLE... 6 FRONT RIGGING:
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Top End Crossfire T6A Ultra Lightweight Active Performance Adjustable Rigid Wheelchair Price List and Order Form Effective September 5, 2008 rev July 24, 2009 For ease of ordering, contact customer Service
VISTA IC PARTS CATALOG
VISTA IC PARTS CATALOG Contents Sideframe (Fixed Arm), Crossbrace & Arm Pad Kit... Sideframe (Detachable Arm) & Crossbrace... Arm, detachable... 5 Upholstery (All sideframes)... 6 Front Rigging... 6 Caster...
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:*
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
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:
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
18 Wide. MRI Transport Wheelchairs. Overall Width: 26 Wheelchair, With Fixed Footrest. Specifications:
MRI Transport Wheelchairs 18 Wide Overall Width: 26 Wheelchair, With Fixed Footrest Removable Full Length Padded Arms Fixed Footrests Seat To Floor Height: 19 1/4 Seat Width: 18 Overall Width: 26 Overall
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:*
Invacare Action 3 Junior Large Retail Max User Weight 80Kg (12.5 stone) Standard Base Price: 539 * Configurations may vary to the image shown
Manual Wheelchair Retail Prescription Form ACTION3JUNIORLARGE15112017 Tel: 01656 776222 Fax: 01656 776220 JAN 2018 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer Ref:
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.
Top End Sports Series
Top End Sports Series Top End T-5 7000 Series Tennis Chair, Pro Tennis, Top End Schulte 7000 Series BB Chair, Pro BB Basketball, Pro-2 All Sport EN Wheelchair User Manual This manual MUST be given to the
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:
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
Quickie GTX Fixed Frame EIF3, Effective July 2009
Quickie GTX Fixed Frame EIF3, Effective July 2009 Account No: Date: P.O. #: Buyer: Marked For: Drop Ship/Ship To: Name: Address: City: State: Zip Code: Phone Number: The HCPCS codes provided are based
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:*
PAGE 2 BREEZY ELEGANCE
PAGE 2 Category... 1 Product... 1... 5 BASE FRAME... 5 AXLE PARTS... 5 CASTER FORK... 6 ANTI-TIP... 7 WHEEL LOCK... 8 DRUM BRAKE... 9 REAR WHEEL - STANDARD... 10 REAR WHEEL - DRUM BRAKE EQUIPPED... 11
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:
Invacare Action 3 Junior Basic RETAIL Max User Weight 80Kg (12.5 stone)
Manual Wheelchair Retail Prescription Form ACTION3JUNIORBASIC05122018 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer
Standard Base Price: 539
Manual Wheelchair Retail Prescription Form ACTION3JUNIORSMALL19102018 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at www.invacare.co.uk Customer
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.
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
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
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
Custom Manual Options & ACCESSORIES AUSTRALIA 2013
Custom Manual Options & ACCESSORIES AUSTRALIA 2013 Casters and Forks CASTERS FORKS Aluminium Soft Roll 4 X 1.5 113395 5 X 1.5 113396 6 X 1.5 113397 Aluminium Polyurethane / Soft Roll Multi Position Fork
SPEEDY 4all "Classicline"
Im Hofstätt 11 D- 72359 Dotternhausen Tel +49 (0)7427 9480-0 Fax +49 (0)7427 9480-7025 e-mail info@proactiv-gmbh.de www.proactiv-gmbh.de Quotation date: Order date: according to GTC PRO ACTIV GmbH SPEEDY
Parts Catalog Issued: Aug 1, Patriot. Wheelchair
Parts Catalog Issued: Aug 1, 2018 Patriot Wheelchair Parts Catalog Usage Guide The information contained in this document is subject to change without notice. This catalog contains service parts for. If
noir 2.0 Order Form NONO Carbon fibre frame made-to-measure. English Company stamp Date User name Responsible Seat depth (PS)
NONO Date User name Order Form Company stamp Rigid frame wheelchair Responsible Carbon fibre frame made-to-measure. Front height 35 37,5 Frame Angle 40 42,5 Backrest rake adjustable from -4 to +16 85 90
Product. QUICKIE QRi PAGE 1
PAGE 2 QUICKIE QRi Product QUICKIE QRi PAGE 1 Category... 1 Product... 1 QUICKIE QRi... 5 BASE FRAME... 5 FRAME... 5 FRAME... 5 TRANSIT KIT... 6 AXLE PLATES AND AXLES... 7 QUICK RELEASE AXLES MATRIX-Q7/QRI/ZONE...
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.
Top End Crossfire. EN Crossfire series Wheelchair User Manual. Crossfire T6, Crossfire Titanium, Crossfire All Terrain
Top End Crossfire Crossfire T6, Crossfire Titanium, Crossfire All Terrain EN Crossfire series Wheelchair User Manual This manual MUST be given to the user of the product. BEFORE using this product, read