Alberta AADL Order Form XL5 and XL5ci manual wheelchair

Transcription

1 lberta L Order Form XL5 and XL5ci manual wheelchair ate: P.O.#: ccount#: Made for (client): Ordered by: Organization: ddress: Phone: Fax: ONFIRM ORER Y E-MIL Yes No SUSRIE TO PHYSIPRO NEWSLETTER Yes No YOUR EMIL RESS 01 XL5 Manual Wheelchair (Seat-to-Floor Height of 13") $ FRME OLORS 02 Glossy lack Silver FRME OULE FOLING MEHNISM TIVE USER, SPSTIITY, RITRI (WE SUGGEST THE OULE ROSS-RE FROM 18" WITH N 250 POUNS N OVER) K POST 06 ack Post Options Straight with push handle 0 8 end with push handle NGLE JUSTLE KREST WITH PUSH HNLE 07 ack ngle K HEIGHT SETTING (WITH JUSTLE UPRIGHTS) 08 ack Height From 15" to 20" esired Height: " 09 Seat Width 14" 15" 16" 17" 18" 19" 20" 21" 22" 23" 24" (The width of the chair when closed is slightly higher for 23" and 24" wide seats.) Seat epth 14" 15" 16" 17" 18" 19" 20" 21" 22" 23" 24" Heavy uty Include reinforced frame and reinforced footrest (Necessary with 23" and 24" width - ouble folding mechanism required) ack Height Modification From 12" to 14" and from 21" to 25" esired Height: " SET UPHOLSTERY N K SET $ 255 $ 280 $ 95 pair 10 Standard Seat Sling 11 Rigid (flat) $ Omit K 13 Standard Upholstery 14 Omit ackrest 15 PREMIUM Tension djustable ack $ 410 Weight apacity: ouble Mechanism Model 350 lb 16 Tension ar $ 165 Tension bar Page 1 of 5

2 RMREST U-TYPE Flip back, removable, height adjustable 17 From 7" to 12" djustable by ½" increments ½" gap on each side $ 285 ea. 18 rmrest Height Modification More than 12" esired Height " $ 112 pair T-TYPE Removable, height adjustable 19 From 9 ½" to 15 ½" djustable by ½" increments ½" gap on each side 20 rmrest Height Modification More than 15 ½" esired Height " $ 112 pair RMP 21 Foam Pad - esk Length (2 ¼" x 10") 22 Foam Pad - Full Length (2 ¼" x 14") FOOTREST N RTIULTING LEGREST FOOTREST Swing away and adjustable in height from 14" to 19" (vailable in black only) $ 149 pair "U" Type "T" Type Foam Pad 26 Footrest Height Modification Less than 14" or over 19" esired Height " (± ¼") ELEVTING N RTIULTING LEGREST alf support and standard footplate included $ 79 pair 27 Pair esired Length (from 14" to 19"): " $ One Legrest Right Left esired Length (from 14" to 19"): " $ 273 LF SUPPORT Included when ordering elevating legrest 29 Standard Padded (6" x 8") $ 155 ea. 30 Profiled Padded (6" x 8") $ 165 ea. FOLING FOOTPLTE 31 omposite, Flip-up Footplate, Standard Size Width 6", epth 6 ¾" 32 luminum, ngle and epth djustable, Standard Size Width 6", epth 6 ¾" $ 180 pair 33 luminum, ngle and epth djustable, Oversized esired Width: 6", 7" or 8" esired epth: 9" or 10" $ 195 pair 34 STRP One Piece Footplate, ngle and epth djustable esired epth: 6", 7", 8", 9" or 10" $ Heel Support Strap djustable in Length 36 alfrest Support Strap $ 120 Page 2 of 5

3 WHEEL LOK 37 Push to lock 38 Pull to lock $ 154 pair 39 Fixed Extension Handle 40 Telescopic Extension Handle $ 60 pair Extension Handle ESSORIES 41 Positioning elt uto uckle, 2" $ nti-tip 43 Transit tie-down STERS 44 Polyurethane 8" x 1 ¼" 45 Polyurethane 5" x 1 ½" 6" x 1 ½" 8" x 1 ½" 46 Polyurethane 4" x 1" 5" x 1" 6" x 1" 7" x 1" $ 100 pair 47 Pneumatic 6" x 1 ¼" 8" x 1 ¼" $ 125 pair RER WHEEL SIZE 48 20" 22" 24" RER WHEEL 49 Mag Wheel 50 Heavy uty Spoke Wheel $ 145 pair RER WHEEL TIRE 51 Polyurethane 52 Standard Pressure Minimum seat-to-floor height is 12" when choosing 20" rear wheel uto uckle Polyurethane Pneumatic HNRIM OPTIONS 53 luminum Handrim 54 Plastic oated Handrim $ 130 pair 55 1/2" loser 56 Omit XLE 57 Threaded 58 Quick Release xle 59 Extension Plates for mputee (integrated to the adjusting plate, position 1, p.5) Page 3 of 5

4 FRONT SET TO FLOOR HEIGHT SELET ESIRE HEIGHT XL5 Hemi Frame Short Fork ½ ½ ½ 13 ½ ½ ½ Standard Frame Short Fork ½ ½ ½ ½ ½ ½ ½ ½ Standard Frame Long Fork 17 ½ ½ ½ ½ ½ ½ ½ ½ ½ ½ 21 Page 4 of 5

5 RER FLOOR TO SET HEIGHT TLE RER WHEEL IMETER XL5 select desired height POSITION 20" 22" 24" ½ 14 ½ 15 ½ ½ 15 ½ 16 ½ E F 15 ½ 16 ½ 17 ½ G H 16 ½ 17 ½ 18 ½ I J 17 ½ 18 ½ 19 ½ E G I F H J. REFERENE SHEME : SET-TO-FLOOR HEIGHT : : RER SET-TO-FLOOR HEIGHT: RER WHEEL POSITION hoose the rear wheel desired position Front of the wheelchair NOTES The positions that are less than 5 become incompatible with a 24" rear wheels and a depth of 16". Page 5 of 5