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

Size: px

Start display at page:

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

Esmond McBride
5 years ago
Views:

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

1 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: /Fax: Catalyst 5Vx K0005 Charge 113 Kg weight capacity Frame Seat Width / Seat Depth Select box corresponding to desired Seat Width and Depth Seat Width Price N/C N/C N/C N/C N/C N/C N/C N/C N/C Heavy Duty Option 160 Kg Weight Capacity Charge Requires minimum 6 caster height Transit Option Transit System K0108 Charge 136 Kg maximum weight capacity. Not available with Removable Seat Pan. Seat Depth 14 N/C 15 N/C 16 N/C N/C 18 N/C Cross Brace Standard Cross Braces Seating System Cross Braces N/C Allows for easy attachment of seating system mounting hardware Not available with Seat Sling or Flip Back Armrests 19 N/C 20 N/C Backrest Back Post / Height Range / Back Height Select Back Height in row corresponding to desired Back Post and Height Range Back Post Standard Price N/C Height Range Back Height Short Medium Tall Standard Back Post Select option below only if a Standard Back Post option is selected on chart at left. Push Handle standard with Angle Adjustable Back Posts. Straight with Push Handle Straight without Push Handle N/C 8º Bend with Push Handle Charge Not available with Short Back Height Range Angle Adjustable Charge Short Medium Tall DCN Pricing and specifications subject to change without notice Page 1 of 8

2 Backrest continued Back Upholstery Standard Not available with Short or Medium Back Height Ranges on Seat Widths Tension Adjustable E2611 Charge Omit Back Upholstery N/C Footrest Hanger / Front Frame Bend 60º N/C Available only with Extension Tube Hangers 70º N/C 80º N/C Not available with 7 or 8 Casters 90º N/C Available only with Front Mount Hangers Elevating Leg Rests E0990 Charge Available only with Composite or Aluminum Angle Adjustable Footplates without Heel Loops Omit Hangers N/C Footplate Heel Loops not included Composite N/C Not available with Front Mount Hangers Foam Loop Charge Not available with Front Mount Hangers or Elevating Leg Rests Aluminum Angle Adjustable K0040 Charge One Piece Flip Up Angle Adjustable K0040 Charge Not available with Front Mount Hangers or Elevating Leg Rests Footrest / Extension / Seat to Footrest Length Select Seat to Footrest Length in row corresponding to desired Footrest and Extension. Footrest Length of at least 2.5 shorter than Front Seat Height recommended. Measurements based on 70º Hanger / Front Frame Bend. Footrest Extension Seat to Footrest Length Extension Tube Hangers (60º, 70º, 80º) Front Mount Hangers 1 Elevating Leg Rests Fixed Front Frame (70º, 80º) Short Medium Long º / 80º º Short Long Short Medium Long Available only with Aluminum Angle Adjustable Footplates 2 Requires 3 Extension for an additional charge Heel Loop Heel Loops E0951 Charge Not available with Elevating Leg Rests or Foam Loop or One Piece Flip Up Angle Adjustable Footplates Omit Heel Loops N/C Calf Strap Not available with Elevating Leg Rests Velcro Adjustable K0038 Charge Padded Velcro Adjustable K0038 Charge Padded AeroMesh K0038 Charge DCN Pricing and specifications subject to change without notice Page 2 of 8

3 Front Seat Height and Casters Caster Size / Front Frame Type / Front Seat Height Select Front Seat Height in row corresponding to desired caster size. Note: selections in fi rst three Front Seat Height columns use Super Low Front Frame. Caster Size Front Seat Height Uses Super Low Front Frame Caster Type.75 Rollerblade N/C Available only with 4 Caster Size.75 Lighted Rollerblade Charge Available only with 4 Caster Size 1 Poly N/C 1 Poly Aluminum Charge Available only with 4 and 5 Caster Sizes 1 Pneumatic Charge Available only with 6 and 8 Caster Sizes 1.5 Poly Charge Available only with 5 and 6 Caster Sizes 1.5 Soft Roll Aluminum Charge Available only with 4, 5 and 6 Caster Sizes 2 Poly Charge Available only with 6 Caster Size 2 Pneumatic w/ Foam Insert Charge Available only with 8 Caster Size Fork Stem Best Fit Ki Mobility will pick optimal Fork Stem based on Caster Size and Front Seat Height Standard Fork Stem N/C 3/4 Longer Fork Stem N/C Longer Fork Stem N/C Fork Options Frog Legs Fork Charge Available only with 4, 5 or 6 Casters. Not available with Caster Pin Locks End User Weight Required: Kgs Caster Pin Locks K0073 Charge Not available with Longer Fork Stem or Frog Legs Fork Wheel Locks Wheel Lock Push to Lock Push to Lock Flush Mount N/C Pull to Lock N/C Short Thro Scissor Lock Charge Omit Wheel Locks N/C Wheel Lock Options Extension Handles E0961 Charge Available only with Push to Lock or Pull to Lock Wheel Locks Grade Aids E0974 Charge Available only with Push to Lock Wheel Locks Available only with Pneumatic or Pneumatic w/airless Insert Rear Tire Types DCN Pricing and specifications subject to change without notice Page 3 of 8

4 Rear Seat Height and Wheels Wheel Size / Tire Profile / Rear Seat Height Select Rear Seat Height in row corresponding to desired Wheel Size and Tire Profile. Wheel Size Tire Profile Rear Seat Height Low Full Low Full Rear Wheel Type Assembled 24 Six-Spoke Mag with Treaded Tire and Composite Handrim N/C No substitutions available. Do not select Rear Tire Type or Handrim. Measures as Full Tire. 24 Spoke N/C Spoke (20, 22, 25 or 26 ) Charge Mag N/C Not available with 25 or 26 Rear Wheel Sizes Superlight Spoke Charge Available only with 24 and 25 Rear Wheel Sizes 24 Low Full All Low Full Rear Tire Type Full Profile Street Pneumatic 1 3/8 Not available on 25 wheels Full Profi le Poly 1 3/8 N/C Not available on Superlight or 25 wheels Pneumatic with Airless Insert 1 3/8 E2211, E2213 Charge Not available on Superlight or 25 wheels Kenda Iron Cap 1 3/8 Grey E2211, E2212 Charge Available only on 24 or 26 wheels. Not available on Mag wheels. Kenda Knobby 1 3/8 Grey E2211, E2212 Charge Available only on 24 wheels Low Profile Low Profi le Poly 1 Charge Not available on Superlight, 25 or 26 wheels Shox Solid Tire 1 E2218 Charge Not available on 20 or 22 wheels High Pressure 1 E2211, E2212 Charge Not available on Mag or 20 wheels Schwalbe Marathon Plus Evolution 1 E2211, E2212 Charge Not available on Mag, 20 or 22 wheels Handrim Standard Handrims Aluminum Anodized Superlight Aluminum Anodized Charge Available only on 24 and 25 Superlight wheels Plastic Coated Charge Projection (8 Vertical Projections) Charge Available on 22, 24, 25 and 26 Spoke wheels & 24 Mag wheels w/full tires Omit Handrim N/C Natural Fit Handrims Not available on 20 wheels or 22 Mag wheels Natural Fit LT Regular Grip Charge Natural Fit Standard Regular Grip Charge Natural Fit LT Super Grip Charge Natural Fit Standard Super Grip Charge Natural Fit LT Omit Grip Charge Natural Fit Standard Omit Grip Charge Handrim Option 3M Micro Grip Charge Not available on Plastic Coated or Projection Handrims Axles Axle Quick Release Quad Quick Release Charge Not available with Mag wheels Axle Position Center of Gravity: Rear Center Forward DCN Pricing and specifications subject to change without notice Page 4 of 8

5 Armrests Armrest Please select Arm Pad option Height Adjustable T-Arm ( ) E0973 Charge Height Adjustable Flip Back ( ) E0973 Charge Not available with Seat Depths less than 16 or Angle Adjustable Back Posts Flip Back (10.5 ) Charge Not available with Seat Depths less than 16 or Angle Adjustable Back Posts Arm Pad Desk Full Not available with Swing Away Armrests Armrest continued Swing Away ( ) E0973 Charge Not available with Angle Adjustable Back Posts or Arm Pads Swing Away with Side Guard ( ) E0973 Charge Not available with Angle Adjustable Back Posts or Arm Pads Omit Armrests N/C Accessories Removable Side Guard Composite Side Guards K0108 Charge Not available with T-Arm, Flip Back or Swing Away with Side Guard Armrests Anti-Tip Rear Anti-Tips E0971 Charge Positioning Belt Auto Buckle E0978 Charge Padded Auto Buckle E0978 Charge 2 Airline Buckle E0978 Charge Bodypoint Evofl ex - Pelvic Stabilizer E0978 Charge Size: Small (16-24 ) Medium (19-29 ) Large (25-37 ) Bodypoint Belt Mounting Kit Charge Style: Bracket Band Clamp 1 Seat Pan Removable Aluminum Seat Pan E2231 Charge Not available with Transit System. Pan depth 1/2 shorter than Seat Depth. Cushion 2 Cushion (14 x14 to 20 x20 ) E2601 Charge 2 Cushion (Over 20 x20 ) E2601 Charge Other Accessories Tool Kit Charge Underseat Pouch Charge Ki Mobility Backpack Charge Black Neoprene Impact Guards Charge Clear Spoke Guards K0065 Charge Not available with Mag wheels Black Spoke Guards K0065 Charge Not available with 20 wheels or Mag wheels Cane and Crutch Holder Charge Frame Color Gloss Finish Black N/C Blue Skies N/C Bubblegum Pink N/C Candy Blue N/C Candy Purple N/C Candy Red N/C Copper N/C Fuchsia N/C Granny Smith N/C Orange N/C Matte Finish Army Green N/C Emerald Green N/C Graphite Gray N/C Iridescent Burgundy N/C Iridescent Navy N/C Retro Red N/C Royal Blue N/C Shadow Black N/C Smooth White N/C Graphic Image Transfer Visit for current graphic image transfer options Note selection below Charge DCN Pricing and specifications subject to change without notice Page 5 of 8

6 Therafin Accessories Vest Full Shape, Comfort Strap (E0960) Charge Small Medium Large X-Large X-Large Full Shape, Extended Strap (E0960) Charge Small Medium Large X-Large X-Large Trip Shape, Comfort Strap (E0960) Charge Small Medium Large X-Large X-Large Trim Shape, Extended Strap (E0960) Charge Small Medium Large X-Large X-Large Shoulder Harness With metal clips and cam locks Small (E0960) Charge Medium (E0960) Charge Large (E0960) 603 Charge X-Large (E0960) Charge Hip Belt 4 Point Y-Style, Metal Buckle (E0978) Charge Small Medium Large Dual Rear Pull, Metal Attaching Clips (E0978) 1 Straps, 6.25 W x 1.75 H Pads Charge 1.5 Straps, 7.25 W x 2.25 H Pads 601 Charge 1.5 Straps, 9.25 W x 2.5 H Pads Charge Single Pull, Metal Buckle (E0978) 1 Straps, 4.25 W x 1.75 H Pads Charge 1 Straps, 5.25 W x 1.75 H Pads Charge 1 Straps, 6.25 W x 1.75 H Pads Charge 1.5 Straps, 5.25 W x 2.25 H Pads Charge 1.5 Straps, 7.25 W x 2.25 H Pads Charge 1.5 Straps, 9.25 W x 2.5 H Pads Charge 2 Straps, 9.25 W x 3 H Pads Charge 2 Straps, W x 3 H Pads Charge Knee Adductor Flip Down Hardware (E1028) Charge Sold in pairs, one right side and one left side. Short Arm, Fits 3/4, 7/8 and 1 Tubing Long Arm, Fits 3/4, 7/8 and 1 Tubing Knee Adductor Pad with Neoprene Cover (E0956) Charge Sold single. Small Pad, 4.25 x Quantity: Medium Pad, 6.25 x Quantity: Foot / Shoe Holder Compatible only with Angle Adjustable Footplates FootSure Ankle Support (K0108) Charge Sold in pairs. X-Small w/ Buckle Closure, 6-8 Circum Small w/ Buckle Closure, Circum Medium w/ Buckle Closure, 8-11 Circum Large w/ Buckle Closure, 9-12 Circum X-Large w/ Buckle Closure, Circum X-Small w/ Hook-N-Loop Closure, 5-6 Circum Small w/ Hook-N-Loop Closure, 6-8 Circum Med w/ Hook-N-Loop Closure, Circum Large w/ Hook-N-Loop Closure, 9-12 Circum X-Lrg w/ Hook-N-Loop Closure, Circum Padded Footbox (K0108) Small, Full Design, Fits 14 Chair Charge Medium, Full Design, Fits 16 Chair Charge Large, Full Design, Fits 18 Chair Charge Small, Split Design, Fits 14 Chair Charge Medium, Split Design, Fits 16 Chair Charge Large, Split Design, Fits 18 Chair Charge Molded Shoe Holders (K0108) Charge Sold in pairs. Small with Plain Straps, 3.5 x Medium with Plain Straps, 4 x Large with Plain Straps, 4.75 x X-Large with Plain Straps, 5 x Cane Mounted Swing Away Lateral Thoracic Support Sold as pair Swing Away Kits w/ 4 x6 Gel Pads (E0956, E1028) Charge Swing Away Kits, No Pads (E0956, E1028) Charge DCN Pricing and specifications subject to change without notice Page 6 of 8

7 Therafin Accessories continued Half Tray Standard Shape, Clear, Flip-Away (E0956, E1028) Charge Right Side Left Side Standard Shape, Padded, Flip-Away (E0956, E1028) Charge Right Side Left Side Trimline Shape, Padded, Flip-Away (E0956, E1028) Charge Right Side Left Side Clear Tray with Border and Pre-Drilled Holes STEP 1: Choose Tray Chair Width Tray Dimension ( W x D ) Body Cutout ( W x D ) HCPCS Part Number Price 20 x x 6 E Charge 20 x x 6.5 E Charge 21 x x 6.5 E Charge 21 x x 7 E Charge 22 x x 7.5 E Charge 22 x x 8.5 E Charge 23.5 x x 8.5 E Charge 23.5 x x 9.5 E Charge 24.5 x x 9.5 E Charge 24.5 x x 10.5 E Charge 26.5 x x 10.5 E Charge 26.5 x x 11 E Charge 26.5 x 22 x 11 E Charge 26.5 x x 11 E Charge 27.5 x x 11 E Charge 27.5 x x 11 E Charge 28.5 x x 11 E Charge 28.5 x x 11 E Charge Communication Mount Hardware Choose Device Holder AND Mount STEP 1: What DEVICE will be used? Smart Phone Charge Large Smart Phone Charge I-Pad Charge I-Pad Mini Charge 7 Tablet Charge 10 Tablet Charge STEP 2: Where does it need to MOUNT? Frame Charge Armrest Charge Tray Charge Cup Holder Heavy Duty Charge Compatible only with Height Adjustable Dual Post Flip Back Armrests STEP 2: Choose Tray Hardware E-Z Lock Clamps, Standard (E1028) Charge Sold in Pairs DCN Pricing and specifications subject to change without notice Page 7 of 8

8 Catalyst Front Seat Height Matrix 4 Caster 5 Caster 6 Caster 7 Caster 8 Caster FSH Stem Fork FSH Stem Fork FSH Stem Fork FSH Stem FSH Stem Fork / / /4 4 3/ / / / / / / x 2 caster not 3/ available with 6 fork.5 3/ / / / / x 2 caster not available with 5 fork Seat heights available with Standard Front Frame. Subtract 1 1/4 when using Super Low Front Frame. Actual seat height may vary up to 1/4. DCN Pricing and specifications subject to change without notice Page 8 of 8

9 Notes and sketches/additional information in detail Custom 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