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.

Size: px
Start display at page:

Download "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."

Transcription

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 Purchase Order * Dealer/Provider Name * Purchaser Name and Contact Information * Billing Address * Tag v Shipping Address * * required F r a m e T y p e Fuze T20 20 Manual Tilt Wheelchair 3,995 F r a m e O p t i o n s Fixed Base and Seat Frame 250 lbs Weight Capacity. Select Fixed Seat Width below Adjustable Base and Seat Frame 250 lbs Weight Capacity. Select Adjustable Seat Width below Transit Tie Down System (TTDS) TTDS includes 4 factory-installed transport brackets. TTDS has been tested according to ANSI/RESNA WC 19. See Owners Manual for complete details. User Weight Range Required for selection of Gas Struts (Force measured in Newton - N) Up to 150 lbs (600 N) lbs to 200 lbs (1000 N) lbs to 250 lbs (1200 N) S e a t W i d t h Overall chair width is +9.5" for 12/16" RW and +10.5" for 20/22/24" RW Fixed Seat Widths Order with Fixed Base and Seat Frame " Seat Width " Seat Width " Seat Width " Seat Width " Seat Width " Seat Width " Seat Width " Seat Width 215 Adjustable Seat Widths Order with Adjustable Base and Seat Frame "-15" Range - Set at 12" "-15" Range - Set at 13" "-15" Range - Set at 14" "-15" Range - Set at 15" "-20" Range - Set at 15" "-20" Range - Set at 18" "-20" Range - Set at 16" "-20" Range - Set at 19" "-20" Range - Set at 17" "-20" Range - Set at 20" "-22" Range - Set at 21" "-22" Range - Set at 22" 215 S e a t D e p t h Standard Seat Depths (Adjustable) " Seat Depth " Seat Depth " Seat Depth " Seat Depth " Seat Depth " Seat Depth F r a m e C o l o u r PDG Premium Colours Tracer Red Black Shimmer Blue Shimmer Geyser Green Bubble Gum Pink Gloss Black Orange Fusion Gloss White Lollypop Blue Berry Purple Silver Karl s Imagination Dark Titanium Lollypop Red Safety Yellow Custom Colour Contact PDG for specifications. 300 PDG Product Design Group Inc. 318 East Kent Ave South Vancouver BC V5X 4N6 Canada Phone / 6

2 A r m T y p e No Armrest Single Post Fixed Height (12") Single Post Adjustable Height 8"-11" not compatible with 22" and 24" Rear Wheels "-11" "-14" Dual Post Fixed Height (12") Full Length Armpad only. Dual Post Adjustable Height 8"-11" not compatible with 22" and 24" Rear Wheels "-11" "-14" "-16" Locking Flip-up Not recommended for users with excessive strength or tone. Not compatible with Fold Down Back, Back Upholstery Set at 10" Set at 11" Set at 12" Set at 13" Set at 14" A r m r e s t s Curved Armpads Not compatible with Lap Tray, Locking Flip-up Armrests, Dual Post Armrests,22" and 24" Rear Wheels. Regular Armpads Desk Length - 2" x 10" Full Length - 2" x 14" Full Length Premium Grade - 2" x 14" 35 Wide Armpads May interfere with wheels in some tilt configurations Desk Length - 3" x 10" Full Length - 3" x 12" Gel Armpads May interfere with wheels in some tilt configurations Full Length - 2" x 12" Full Length - 3.5" x 12" Contour Arm Trough with Hand Pad May interfere with wheels in some tilt configurations Right (4.5" x 18") Left (4.5" x 18") S e a t P a n No Seat Pan Solid Aluminum Seat Pan 120 C u s h i o n No Cushion nxt BioFit "-20" width, 16"-20" depth "-24" width, 16"-20" depth 625 Cushion Size Available in even number sizes only Specify Size (Width" x Depth") PDG Product Design Group Inc. 318 East Kent Ave South Vancouver BC V5X 4N6 Canada Phone / 6

3 S e a t H e i g h t Select desired Seat-to-Floor Height Standard T20 Options Narrow T20 Options RW 5" Casters Reduces the overall width of the Chair by 2". 12" 13" Recommended only if the width of the chair is a 16" 13" 14" 15" concern. Some STF combinations offer less than 20 of tilt, but all offer a minimum of " 13" 14" 15" 16" 17" 22" 14" 15" 16" 17" RW 5" Casters 24" 15" 16" 17" 12" 13" 14" 16" 14" 15" 16" RW 6" Casters & 6" Forks 20" 16" 17" 16" 14" 15" 22" 17" 20" 14" 15" 16" 17" 22" 14" 15" 16" 17" 18" RW 6" Casters & 6" Forks 24" 15" 16" 17" 18" 12" 14" 16" 14" 15" 16" RW 6" Casters & 8" Forks 20" 16" 17" 18" 16" 15" 22" 17" 18" 20" 15" 16" 17" 24" 18" 22" 15" 16" 17" 18" 24" 15" 16" 17" 18" 19" RW 6" Casters & 8" Forks 16" 15" 16" RW 8" Casters & 8" Forks 20" 16" 17" 18" 20" 16" 17" 22" 17" 18" 19" 22" 16" 17" 18" 24" 18" 19" 24" 16" 17" 18" 19" RW 16" 8" Casters & 8" Forks 16" 20" 16" 17" 18" 22" 17" 18" 19" 24" 18" 19" 20" Standard Narrow Wheel size Caster size Fork size STF height Urethane 5" x 1.25" Caster size 6" x 1.25" Caster size 6" x 1.50" Caster size 8" x 1.25" Caster size " x 2.00" Caster size Pneumatic 6" x 1.25" Caster size 8" x 1.25" Caster size " x 2.00" Caster size " Soft Roll 95 Composite " Wheel size " Wheel size " Wheel size " Wheel size C a s t e r s R e a r W h e e l s " Wheel size Spoke " Wheel size " Wheel size " Wheel size " Heavy Duty Spoke 350 A x l e T y p e Quick Release Rear Axles Fixed Rear Axles PDG Product Design Group Inc. 318 East Kent Ave South Vancouver BC V5X 4N6 Canada Phone / 6

4 R e a r T i r e s Urethane Pneumatic Pneumatic Tires may result in a finished Seat Height 1/2" greater than stated Pneumatic with Flat-Free Inserts 95 H a n d R i m s Pneumatic Tires may result in a finished Seat Height 1/2 greater than stated. Not compatible with Spoke Wheels No Hand Rims Standard 20", 22", and 24" Rear Wheels only Plastic Coated 20", 22", and 24" Rear Wheels only Push to Lock Pull to Lock Attendant Wheel Lock (Push to Lock) Not compatible with Wheel Lock Extensions User & Attendant Wheel Lock Wheel Lock Extensions Not compatible with Attendant Wheel Lock Rear Anti-Tippers Required Safety Option Push Bar Back Straight Bend 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 Cane Handle Back Straight Not compatible with Headrest Mounting Plate Bend 75 Back Post Height Seat Pan to Handle " Height " Height B a c k O p t i o n s Angle/Height Adjustable Push Bar Handle Not compatible with Headrest Mounting Plate or Cane Handle Back Button on Outside Button on Inside Removable Cane Handle Push Bar Not compatible with Push Bar Back. 140 Seat to Back Angle Set at Set at Set at Set at Set at Set at Fold Down Back Non Fold Down Back 75 B a c k U p h o l s t e r y No Back Upholstery Standard Back height measured from Seat Pan to top of Upholstery. Not available with Cane Handle Back Set at 18" Set at 19" Set at 20" Set at 21" Set at 22" Set at 23" Adjustable Tension Back height measured from Seat Pan to top of Upholstery. Not available with Cane Handle Back Set at 21" Set at 22" Set at 23" PDG Product Design Group Inc. 318 East Kent Ave South Vancouver BC V5X 4N6 Canada Phone / 6

5 B a c k r e s t No Backrest nxt Xtend "-20" width, 16"-20" height "-24" width, 16"-20" height 720 nxt Xtend Deep "-20" width, 16"-20" height "-24" width, 16"-20" height 720 Backrest Size Available in even number sizes only Specify Size (Width" x Height") T i l t / R e c l i n e O p t i o n s Attendant Tilt only Trigger on Right Back Post Trigger on Left Back Post H e a d r e s t No Headrest Headrest Mounting Plate 75 Not compatible with Angle/Height Adjustable Push Bar, Cane Handle Back. Not required if mounting to a solid Back nxt MultiFit Head Support Hardware 235 nxt MultiFit Head Support Pad Regular (9" x 5") Large (10" x 5") X-Large (14" x 5") F r o n t R i g g i n g No Front Rigging Sector Blocks only PDG Easy-Out TM Front Rigging Effortless insertion and removal. No Hanger Bracket remains on frame Fixed Swing In/Away Universal Angle Adjustable (0-110 ) Set at (use increments of 10 ): Swing In/Away Elevating Legrests High knee pivot. Includes reinforced premium Calf Pad mount. 495 Standard Front Rigging Legacy Design. Not compatible with Easy-Out TM Swing Away Swing Away 90 Not compatible with 8" Casters Swing Away Elevating Legrest " Offset Hangers for Swing Away 75 F o o t P l a t e s Composite Aluminum Angle Adjustable Interlocking Angle Adjustable Seat Widths of 14"-21" only. 195 F o o t r e s t / L e g r e s t A c c e s s o r i e s Swing Away 70 Calf Pad Not compatible with 70 Gel Padding Swing Away 70 Gel Padding Not compatible with 70 Swing Away Calf Pad, Easy-Out Front Rigging Swing Away ELR Gel Knee Pad Adjustable Length Heel Loops Bodypoint - Padded Calf Strap 105 PDG Product Design Group Inc. 318 East Kent Ave South Vancouver BC V5X 4N6 Canada Phone / 6

6 Short 14"-18" for Easy-Out Fixed & SA Angle Adjustable 11"-15" for Easy-Out SA ELR 13"-17" for Standard Front Rigging Long 18"-24" for Easy-Out Fixed & SA Angle Adjustable 15"-21" for Easy-Out SA ELR 15"-19" for Standard Front Rigging For 90 FR (11"-16") Not compatible with Easy-Out, Standard 70 or ELR Lap Belt Mount E x t e n s i o n T u b e s P o s i t i o n i n g S t r a p s Bodypoint - Hip Belts Center-Pull Auto Style Center-Pull Auto Style, Padded Point, Padded Bodypoint - Chest Strap 85 M i s c e l l a n e o u s O p t i o n s Gel Hip Guides Not compatible with Dual Post Arms. Reduces available Seat Width by 2" IV Pole 15" STF and higher O2 Holder 15" STF and higher Clear Lap Tray (Slide On) Not compatible with 8-11 Dual Post, Curved Armpads, Contour Arm Trough. Seat Widths of only. 490 Premium Grade or Gel Armpads recommended to ensure snug fit of the Tray Adhesive Back Hook Strip, 2" x 30" For Cushion mounting Fuze T20 to T50 Conversion Kit O r d e r N o t e s Please send your completed order form by to or by fax to Scan this code or go to pdgmobility.com/products/fuze-t20/ to learn more about the Fuze T20 20 Manual Tilt Wheelchair PDG Product Design Group Inc. 318 East Kent Ave South Vancouver BC V5X 4N6 Canada Phone / 6

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.

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

More information

BENTLEY. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.

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

More information

STELLAR. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.

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

More information

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.

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

More information

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

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

More information

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.

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

More information

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.

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

More information

FUZE T50. Order Form USA. Please send your completed order form by to or by fax to

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

More information

USA Parts List FUZE T20

USA Parts List FUZE T20 USA Parts List FUZE T20 Effective January 1, 2018. Prices in U.S. Dollars. Prices and descriptions contained in this manual are subject to change without prior notice. Fuze T20 Frame-Seat Pan Cross Bar

More information

USA Parts List FUZE T50

USA Parts List FUZE T50 USA Parts List FUZE T50 Effective January 1, 2018. Prices in U.S. Dollars. Prices and descriptions contained in this manual are subject to change without prior notice. Fuze T50 Frame-Seat Pan Cross Bar

More information

USA Parts List BENTLEY

USA Parts List BENTLEY USA Parts List BENTLEY Effective January 1, 2018. Prices in U.S. Dollars. Prices and descriptions contained in this manual are subject to change without prior notice. Bentley Frame-Seat Pan Floor Jack

More information

Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018

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

More information

4.2 HELIO KIDS MODEL. Ultralight Folding Carbon Fiber HELIO KIDS Wheelchair Including angle & depth adjustable back (79 kg lbs weight capacity)

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

More information

4.1 MOVE. ORDER FORM - CANADA Ship to: Name: Address: Account: Vendor: Date: Ordered by: Marked for: User manual: PO: Postal Code: Phone:

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 information

Invacare Action 3 Junior Basic RETAIL Max User Weight 80Kg (12.5 stone)

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

More information

Spare Parts Catalogue. Version: 2014/10/08b EN

Spare Parts Catalogue. Version: 2014/10/08b EN Spare Parts Catalogue TABLE OF CONTENTS Chassis Sideframes... Crossbrace... 5 6 Seat Seat Upholstery... Solid Seat Inserts..... 7 8 Backrest Legrests Back Cane Assemblies... 9 Back Upholstery... 10 Push

More information

Invacare Action 3 NG Transit Retail Max User Weight 125Kg (19.7 stone)

Invacare Action 3 NG Transit Retail Max User Weight 125Kg (19.7 stone) Manual Wheelchair Retail Prescription Form ACTION3NGTRANSIT10112016 Tel: 01656 776222 Fax: 01656 776220 JAN 2017 Email: ordersuk@invacare.co.uk Online Spares available at www.invacare.co.uk Customer Ref:

More information

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

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:

More information

Account Number: Provider Name: Contact:

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

More information

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.

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

More information

Standard Base Price: 539

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

More information

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. 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 information

4.2. Ship to: Vendor: Name: Date: Address: Ordered by: City: Province:

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

More information

Invacare Action 3 Junior Large Retail Max User Weight 80Kg (12.5 stone) Standard Base Price: 539 * Configurations may vary to the image shown

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:

More information

Account Number: Provider Name: Contact:

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

More information

Tilt in space up to 60 degrees Comfort seating Max. user weight: 113kg. Height adjustable folding back Heavy Duty version 158kg

Tilt in space up to 60 degrees Comfort seating Max. user weight: 113kg. Height adjustable folding back Heavy Duty version 158kg QUICKIE IRIS Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: E-Mail: E-Mail: Tel: Fax: Tel: Order date: Marked for: Purchase order: Number required: Sunrise order no: Base

More information

4.2. Ship to: Vendor: Name: Date: Address: Ordered by: Phone:

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

More information

MASS Script Form. 160 Kg Weight Capacity Charge. Transit Option. 136 Kg maximum weight capacity. Not available with Removable Seat Pan.

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

More information

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) Freedom 2 Kids

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

More information

4.6. Clinician/ATP/RTS: City: State: C2MA029 * Required

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:*

More information

q Little Wave Flip XP-Rigid Base E1233, E1161 $

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

More information

Standard Base Price: 618

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

More information

Convaid Trekker 2 - HCPCS E1234 Canadian Retail Price List / Order Form

Convaid Trekker 2 - HCPCS E1234 Canadian Retail Price List / Order Form Account #: Contact: Canadian Retail Price List / Order Form Purchase Order #: Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email: Ship To: Address: City/State/Zip: Phone: TR14 Base Accepts

More information

Convaid Trekker 2 - HCPCS E1234 Retail Price List / Order Form

Convaid Trekker 2 - HCPCS E1234 Retail Price List / Order Form Account #: Contact: Retail Price List / Order Form Purchase Order #: Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email: Ship To: Address: City/State/Zip: Phone: TR14 Base Accepts TR12 & TR14

More information

4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required MVMA053 MVMA056. MVMA058 English Manual (STD) Dutch Manual

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.

More information

18 Wide. MRI Transport Wheelchairs. Overall Width: 26 Wheelchair, With Fixed Footrest. Specifications:

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

More information

RETAIL Max user weight: 100kg - seat widths 12" & 13" Max user weight: 130kg -seat widths 14" -16"

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

More information

MOVE ORDER FORM - CANADA

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:

More information

q Little Wave Flip XP - Rigid Base KF-XPRIGID $

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

More information

discovery tmax Base price: EUR x,xxx q Provide estimate only q Order q Order no.: Attachment for custom fabrication enclosed

discovery tmax Base price: EUR x,xxx q Provide estimate only q Order q Order no.: Attachment for custom fabrication enclosed BITTE DETACH HIER HERE ABTRENNEN AND SEND UND BY ZU FAX OTTO TO OTTO BOCK BOCK FAXEN Base price: EUR x,xxx All prices in EUR, valid from 01/01/2012 to 31/12/2012 Order no.: discovery tmax Article number:

More information

STD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD +1" +2" STD

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:*

More information

Invacare Kite (Modulite Flex3 Seating System) Dealer Max User Weight 160Kg (25 stone)

Invacare Kite (Modulite Flex3 Seating System) Dealer Max User Weight 160Kg (25 stone) Invacare Ltd Power Prescription Form Pencoed Technology Park Dealer Prescription Form Pencoed CF35 5AQ LPF1U2KITEFLEX011015Dealer Tel: +44 (0) 1656 776222 Fax: +44 (0) 1656 776220 July 2015 email: ordersuk@invacare.com

More information

Quickie IRIS January 2014

Quickie IRIS January 2014 Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: ST: ZIP: Address: Dealer Phone: ( ) Fax: ( )

More information

MASS Script Form. Frame. Backrest. Seat Depth. Tsunami ALX K0005 Charge. Sling Position. Seat Width / Seat Depth. Seat Width.

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

More information

Height adjustable footplates, equipped with nylon heel loops. Standard with maintenance free PU front (7 ) and rear wheels (24 ).

Height adjustable footplates, equipped with nylon heel loops. Standard with maintenance free PU front (7 ) and rear wheels (24 ). Excel G-lite + Compact foldable aluminium wheelchair Perfect for taking with you wherever you go due to its light transport weight and compact size. Comfortable back upholstery. Height adjustable comfortable

More information

SHIPPING INFORMATION Provider Acct #:

SHIPPING INFORMATION Provider Acct #: May 2014 Kids ROCK TM Size 2 Order Form Maximum Weight Capacity 115 lbs. 14"Wx16"Dx22"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING

More information

Traxx 3 & Atigra 2 Script Form

Traxx 3 & Atigra 2 Script Form Traxx 3 & Atigra 2 Script Form Client Information Address Therapist Information Organisation Email Phone Height Weight Funding Source Salesperson Information Company Traxx 3 Atigra 2 Standard Features

More information

NXT Pediatric. Manual Wheelchair. Transport Optional Base

NXT Pediatric. Manual Wheelchair. Transport Optional Base Pediatric Manual Wheelchair Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Transport Optional Base Folding (E1234) NXT-30300 $2800 Transport Optional Note: Transportation Option selected

More information

Quickie IRIS FSS Net Order Form/Price List (SIN F-1)

Quickie IRIS FSS Net Order Form/Price List (SIN F-1) Mark For: Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: Dealer Phone: ( ) Fax: ( ) Confirmation Email: Confirm Via: ZIP: Quickie IRIS FSS Net Order Form/Price List (SIN

More information

SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5

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...

More information

3 A7WC10 E-Motion adaptor Kit (2 adaptors)

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.

More information

M1 - NPO. Dealer Information. Client Information. Client Measurements

M1 - NPO. Dealer Information. Client Information. Client Measurements Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * Province: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client is evaluated by a certified

More information

Invacare. Family Compatibility Portfolio Optimize your business with an all-in-one solution. Jan

Invacare. Family Compatibility Portfolio Optimize your business with an all-in-one solution. Jan Invacare Family Compatibility Portfolio 2012 Optimize your business with an all-in-one solution. Content Introduction 3 How to use this publication 3 Pictograms 3 Technical information 4 Products overview

More information

4.6. Clinician/ATP/RTS: City: State: VEMA039 * Required. Veloce - FRONT Seat-to-floor height. 16 to 19 Specify desired height: 80.

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:*

More information

Quickie QX July 2017

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

More information

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

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

More information

NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS

NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS 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"

More information

Transport Chairs / Walkers MRI Transport

Transport Chairs / Walkers MRI Transport MRI Folding Walkers 18 Wide, Depth 17 250 lb weight capacity WA-1000 Adult - 32 to 36 $195.00 ea. WA-1001 Junior - 28 to 32 $195.00 ea. MRI Heavy Duty / Extra Wide Folding Walker 24 Wide, Depth 21 500

More information

SIDEFRAME (FIXED ARM), CROSSBRACE, ARM PAD KIT...3 SIDEFRAME (DETACHABLE ARM), CROSSBRACE...4 ARM, DETACHABLE...5 CASTER...5 REAR WHEEL...

SIDEFRAME (FIXED ARM), CROSSBRACE, ARM PAD KIT...3 SIDEFRAME (DETACHABLE ARM), CROSSBRACE...4 ARM, DETACHABLE...5 CASTER...5 REAR WHEEL... PARTS CATALOG CONTENTS SIDEFRAME (FIXED ARM), CROSSBRACE, ARM PAD KIT... SIDEFRAME (DETACHABLE ARM), CROSSBRACE... ARM, DETACHABLE...5 CASTER...5 REAR WHEEL...5 FRONT RIGGING, DETACHABLE...6 UPHOLSTERY

More information

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"

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.

More information

MASS Script Form. Frame. Backrest. Seat Depth

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

More information

SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5

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...

More information

Quickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,

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:

More information

SHIPPING INFORMATION Provider Acct #:

SHIPPING INFORMATION Provider Acct #: May 2014 Kid's ROCK TM Size 3 Order Form Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING

More information

Quickie QX December 2018

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:

More information

discovery tmax Base price: EUR x,xxx q Provide estimate only q Order q Order no.: Attachment for custom fabrication enclosed

discovery tmax Base price: EUR x,xxx q Provide estimate only q Order q Order no.: Attachment for custom fabrication enclosed BITTE DETACH HIER HERE ABTRENNEN AND SEND UND BY ZU FAX OTTO TO OTTO BOCK BOCK FAXEN Base price: EUR x,xxx All prices in EUR, valid from 01/01/2012 to 31/12/2012 Order no.: discovery tmax Article number:

More information

Helio A6 ORDER FORM - CANADA

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:*

More information

Condor Script Form Folding Frame Day Wheelchair 90050

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

More information

NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS STABLE

NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS STABLE 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

More information

MEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:

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

More information

Table of Contents. Tilt Wheelchair. Folding Wheelchair. power Wheelchair. commodes. At Power Plus Mobility, We care!

Table of Contents. Tilt Wheelchair. Folding Wheelchair. power Wheelchair. commodes. At Power Plus Mobility, We care! Table of Contents 01 05 09 Tilt Wheelchair STP EXTREME NV TILT 13 17 21 Folding Wheelchair MAGIC PLUS VOYAGER PLUS GLYDER 25 power Wheelchair MP5 29 31 commodes HORIZON HORIZON TILT At Power Plus Mobility,

More information

C2 FRONT Seat-to-floor Height - Please select your choice. Custom Technologies Limited. 40 Raywood Crescent TAUPO. New Zealand

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.

More information

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

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:*

More information

Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.

Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements. AADL W592/W991 Quantum Q6 Edge 2.0 with TB3 Power Positioning FOR AADL USE ONLY Pride Mobility Products Co. 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Discount:

More information

SpectraXTR2 HD (Modulite Flex 3 Seating or MAX System) Dealer Max User Weight 160Kg (25 stone)

SpectraXTR2 HD (Modulite Flex 3 Seating or MAX System) Dealer Max User Weight 160Kg (25 stone) Invacare Ltd Power Chair Prescription Form Pencoed Technology Park Dealer Prescription Form Pencoed CF35 5AQ LPF1U2SPECTRAXTR2HD010715DEALER Tel: +44 (0) 1656 776222 Fax: +44 (0) 1656 776220 July 2015

More information

Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.

Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements. AADL W659/W991 Quantum Q6 Edge Z with TB3 Power Positioning FOR AADL USE ONLY Pride Mobility Products Co. 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Discount:

More information

Küschall Ultra Light RETAIL Maximum user weight 130kg (20.5 Stone)

Küschall Ultra Light RETAIL Maximum user weight 130kg (20.5 Stone) 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

More information

Adjustable Height Raised Toilet Seat Model 101 RTS Pricelist/Order Form December 2014

Adjustable Height Raised Toilet Seat Model 101 RTS Pricelist/Order Form December 2014 Adjustable Height Raised Toilet Seat Model 101 RTS Date: Name: P.O.#: Address: Name: City/State/Zip: Mark For: Phone: Account #: Fax: This Activeaid raised toilet seat is unique in its design to accommodate

More information

Condor Script Form Folding Frame Day Wheelchair 90050

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

More information

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) PRO-CG. Adult Manual Wheelchair

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) PRO-CG. Adult Manual Wheelchair PRO-CG Adult Manual Wheelchair email: customerservice@freedomdesigns.com TM SE Clear Form Email Form to Customer Service Date: Buyer: Company: Email: Quote Order PO# Location: Phone: Fax: Notice: A seating

More information

MEDIchair Northern BC nd Avenue Prince George, British Columbia V2L 3A6 Toll Free

MEDIchair Northern BC nd Avenue Prince George, British Columbia V2L 3A6 Toll Free MEDIchair Northern BC 849 2 nd Avenue Prince George, British Columbia V2L 3A6 Toll Free 1-800-330-2772 BC Ministry of Health A Cheat Sheet for Clinicians Included Features for a Basic Wheelchair, Basic

More information

Frame. Backrest. Seat Depth. Little Wave - Clik XP $3600 Width Growable Frame. Price includes one time free growth kit. 165 lb weight capacity.

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

More information

Invacare Kite (Max Seating System) Retail Max User Weight 160Kg (25 stone)

Invacare Kite (Max Seating System) Retail Max User Weight 160Kg (25 stone) Power Wheelchair Retail Prescription Form KITEMAX210917 Tel: 01656 776222 Fax: 01656 776220 OCTOBER 2017 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Account No : Contact

More information

Order no.: ... Date Signature. Posterior seat height

Order no.: ... Date Signature. Posterior seat height Start M6 Junior Scripted Order no.: Start M6 Junior Lightweight wheelchair Article number: 480F53=60000_K Provide estimate only Order Billing address/customer number Ottobock START_M6_647F263=EN-05-1510

More information

Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA Sales: Phone: (866) Fax: (866)

Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA Sales: Phone: (866) Fax: (866) This product is available for purchase online at www.mypride.com Account #: Date: Order No. Fax No. Phone No. PAGE 1 Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Sales: Phone:

More information

4.6. A7 FRONT Seat-to-floor Height - Please select your choice. Stem bolt Length /2 15 1/2 16 1/2

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:*

More information

BREEZY EC WHEELCHAIRS. The best combination of durability, selection and value.

BREEZY EC WHEELCHAIRS. The best combination of durability, selection and value. BREEZY EC WHEELCHAIRS The best combination of durability, selection and value. Breezy EC 2000 A quality wheelchair with options offering the flexibility to accommodate a variety of users. Standard Features

More information

For the Modulite Teen seating please select the underlined options on this form and include a completed Modulite Teen Seating form

For the Modulite Teen seating please select the underlined options on this form and include a completed Modulite Teen Seating form Power Wheelchair Retail Prescription Form BORAMOD111217 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2018 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account

More information

4.8. Clinician/ATP/RTS: City: State/Prov: Marked for: Phone: * Required KDMA063 English Manual (STD) Manuel Français

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:*

More information

Stallion Script Form Fixed Frame Adjustable Wheelchair 90100

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

More information

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:

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:*

More information

APEX 4.6. FRONT Seat-to-floor height Caster sizes Height available +- 1/4" ORDER FORM - International. 3" Caster. Specify desired height:

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:*

More information

Helio A6 ORDER FORM - CANADA

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:*

More information

Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:

Account Number: Provider Name: Contact Name: Phone #: Fax #:  Address: Taken By: Client Height: Client Weight: Quantum Q6400Z Series Group 4 Order Form 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866)

More information

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG. Adult Manual Wheelchair

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG. Adult Manual Wheelchair P.R.O. CG Adult Manual Wheelchair TM SE 2241 N Madera Rd Simi Valley, CA 93065 Phone: (800) 331-8551 Fax: (888) 582-1509 www.freedomdesigns.com email: customerservice@freedomdesigns.com Date: Buyer: Company:

More information

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG P.R.O. CG 2241 N Madera Rd Simi Valley, CA 93065 Phone: (800) 331-8551 Fax: (888) 582-1509 www.freedomdesigns.com Date: PO# Adult Manual Wheelchair TM SE Date: Buyer: Company: Email: Quote Order PO# Location:

More information

BC MEDEQUIP HOME HEALTH CARE LTD SPRINGER AVE, BURNABY, BC

BC MEDEQUIP HOME HEALTH CARE LTD SPRINGER AVE, BURNABY, BC Basic Wheelchair Bid Work Sheet HMEDA Member Name/Address: BC MEDEQUIP HOME HEALTH CARE LTD. 2230 Springer Avenue, Burnaby, BC, V5B 3M7 Contact Person: ANDRE MONTAGANO Phone/e-mail: 604-888-8811 andre@bcmedequip.com

More information

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:

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:*

More information

R82 Stingray. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: City/State/Zip: Effective: 2/01/ Rev 7.

R82 Stingray. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: City/State/Zip: Effective: 2/01/ Rev 7. R82 Stingray CAD Retail Price List/ Order Form Account #: Purchase Order No.: Date: Contact: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US Configuration

More information

Please make your selection with a cross in the box Standard feature Free of Charge

Please make your selection with a cross in the box Standard feature Free of Charge 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

More information