Condor Script Form Folding Frame Day Wheelchair 90050
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- Natalie Riley
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1 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 page. Send form If online, click here to send via Date Delivery details Address Therapist details Phone Fax / Cell Required by Trial Chair Ref: Disability Weight Height Shoe Size T-Shirt Size MEASUREMENTS (Refer to diagram) Max User Weight 125kg Materials Aluminium (std) Titanium 90050T A Seat width A Custom seat width AD10100 B Seat depth B Custom seat depth AD10100 B Growth option in seat depth AD10800 C Back height D Back angle (0 or 5 ) E Seat to footplate F Seat to floor - front G Seat to floor - rear H Balance Point I Camber (0, 3, 5 ) J Hanger Angle (70, 80 or 90 ) K Dynamic Rocker Back AD10330 Axle plate Standard Amputee Additional User weight up to 165kg Reinforced Aluminium frame AD10400 Reinforced Titanium frame AD10410 Additional Notes (you can type here) D C B I A K J G H F E
2 PAGE 2 HANGER TYPE Swing Away Drop In (top) Drop In Fixed FOOT-PLATE WIDTH Width for Pro T and V style foot-plates When measuring across feet you must add 2 (50mm) SWING AWAY FOOTREST Straight swing away Pro T swing away V swing away Straight swing away Pro T swing away V swing away Straight Hangers 2 piece flip up plastic foot-plate (std) 2 piece flip up, angle adjustable foot-plates AD11521 Pro T Hangers 1 piece flip up, angle adjustable, alloy foot-plate, opens to the left AD11450 V Hangers 1 piece flip up, angle adjustable, alloy foot-plate, opens to the right (pictured) AD11450 DROP IN FOOTREST Straight drop in D foot-plate Pro T drop in D foot-plate Straight drop in angle adj Pro T drop in angle adj Straight Hangers D style foot-plate (std) ABS on foot-plate AD11500 Pro T Hangers Angle adjustable foot-plate AD11520 FIXED FOOTREST Straight fixed Pro T fixed V fixed Straight fixed Pro T fixed V fixed Straight Hangers 2 piece flip up plastic foot-plate (std) 2 piece flip up, angle adjustable foot-plates AD11521 Pro T Hangers 1 piece flip up, angle adjustable, alloy foot-plate, opens to the left AD11450 V Hangers 1 piece flip up, angle adjustable, alloy foot-plate, opens to the right (pictured) AD11450 ELEVATING LEG REST Made for the Swing Away front only Left AD11610 Right AD11610 Both AD11600 STUMP SUPPORT Left AD11650 Right AD11650 Both AD11651 Made for the Fixed and Swing Away fronts only Fixed Removable
3 PAGE 3 CASTORS 4 wide solid composite (std) 5 solid composite (std) 6 solid composite (std) 8 x 1 solid composite AD x 1.25 alloy AD wide solid composite (std) 6 wide solid composite (std) 8 floater wide composite AD wide soft roll alloy AD solid alloy AD solid alloy AD pneumatic composite AD x 1.5 alloy AD x 1.5 alloy AD wide soft roll alloy AD wide soft roll alloy AD pneumatic composite AD11750 FORKS Standard forks (std) Frog Legs suspension AD11950 PUSH HANDLES Nil In back canes (std) Stroller D AD14200 Dual clamp adj height AD14120 Foldable in back canes AD14160 Strollers twin removable AD14240 Stroller handle with AD14300 ratchet backrest BRAKES Nil Pull to lock AD14510 Reverse handles Scissor AD14520 Push to lock (std) Hill climbers AD14530 Scissor Lock Composite AD14570 Push to lock (long handle) AD14551 Brake extensions AD14550 ANTI-TIPS Nil With plastic wheels Stainless Steel with plastic wheels AD15025 Adjustable anti tips AD15010 Kick tube AD15040 With roller-blades AD15030 Flared w/plastic wheels AD15020 Swing under anti tips AD15060 (only for w/chairs smaller than 16 wide) ARMRESTS Nil Foam tube swing away, lift out AD15200 Desk pad swing away, lift out AD15210 Full pad swing away, lift out AD15220 T adjustable height with desk pad armrest AD15260 T adjustable height with full length pad armrest AD15261 T adjustable height desk pad armrest with ABS skirt guard AD15280 T adjustable height full pad armrest with ABS skirt guard AD15281 UPHOLSTERY Sling (std) Tension adjustable back (std) No cushion Bag under chair AD16600 No back upholstery Cushion 1 AD16201 Bag on back of chair AD16680 To fit solid back Cushion 2 AD16202 Bag on front left hanger AD16620 Cushion 3 AD16203 Bag on front right hanger AD16620 SKIRT GUARDS Nil Fabric skirt guards AD16100 ABS skirt guards drop in AD16110 STRAPS / BELTS, COVERS / GUARDS Leg strap (std) Fabric foot-plate cover AD11510 Seat belt - plastic buckle AD16500 or Heel loop straps (std) Castor pivot covers AD16410 Seat belt - adults car buckle AD16522 Hanger Impact guards (std) TRAY TIE DOWN MOUNTS Nil 2 front and 2 rear AD10320 Slides over armrests AD17000 With prong receivers AD17010
4 PAGE 4 WHEELS Transit Wheels 16 x 1.75 Composite Wheels 18 x 1 Spoked Wheels 18 x 1.75 Composite Wheels 20 x 1 Spoked Wheels 20 x 1-3/8 Spoked Wheels 20 x 1.75 Spoked Wheels 22 x 1 Spoked Wheels 22 x 1-3/8 Spoked Wheels 22 Spinergy LX Wheels (12 spoke - black only) AD Spinergy Day Wheels (18 spoke) AD13300 Spinergy LX Wheels (12 spoke) AD13310 Spinergy LX Wheels with FlexRim (12 spoke - black only) AD13315 X Core Wheels (5 spoke) AD x 1.75 BMX Wheels (std) 25 Spinergy Day (18 spoke) AD13300 Spinergy LX (12 spoke) AD13310 Spinergy LX Wheels with FlexRim (12 spoke - black only) AD13315 X Core Wheels (3 spoke) AD x 1.95 BMX Wheels (std) 26 Spinergy Day (18 spoke) AD13300 Spinergy LX (12 spoke) AD x 1.75 BMX Wheels (std) Spare Wheel(s) Type: Tyres: Pushrims: Size: TYRES Tread (std) 16 x 1.75 Tread (std) 18 x 1 HP Smooth (std) 18 x 1.75 Tread (std) 20 x 1 HP Smooth (std) 20 x 1-3/8 Tread (std) 20 x 1-3/8 Solid Tread (std) 20 x 1.75 Tread (std) 22 x 1 HP Smooth (std) 22 x 1-3/8 Tread (std) 22 x 1-3/8 Solid Tread (std) x 1 HP Smooth (std) 24 x 1 HP Tread (std) 24 x 1 Solid (std) 24 x 1-3/8 Tread (std) 24 x 1-3/8 Solid (std) 24 x 1-3/8 Kenda HP Tread AD x 1-3/8 Primo V-Trak Knobbly AD x 1 Kenda Ironcap Blue AD x 1 Kenda Konstrictor AD x 1 Schwalbe Right Run AD x 1 Schwalbe Marathon Evo AD x 1.75 BMX Tread (std) x 1 HP Smooth (std) 25 x 1 Solid (std) 25 x 1 Kenda Ironcap Blue AD x 1 Kenda Konstrictor AD x 1 Schwalbe Right Run AD x 1 Schwalbe Marathon Evo AD x 1.95 BMX Tread (std) x 1 HP Smooth (std) 26 x 1-3/8 Tread (std) 26 x 1 Solid (std) 26 x 1 Schwalbe Right Run AD x 1 Schwalbe Marathon Evo AD x 1.75 BMX Tread (std) PUSHRIMS Anodised (std) Rubber coated (black) AD13850 Foam AD13840 Natural Fit no thumb grips AD13860 Anodised (1 ) AD13855 Rubber coated (1 ) AD13857 Spinergy FlexRim - see Wheels Natural Fit with thumb grips AD13860 Vinyl AD13830 Surge AD13864 Max Greppe AD13870 Vinyl (1 ) AD13859 Capstan No. of projections: Angle: Length: PUSHRIMS - POSITION AXLES SPOKE GUARDS Standard In close Quick release axles (std) Clear polycarb AD13900 Onto rim Quad release AD12500 Black ABS AD13901
5 PAGE 5 Attention This is a guide to colours only, how colours appear on your monitor or when printed out may vary. Talk to us if you want your Titanium frame coloured or polished. Colour availability is subject to change without notice. standard & ENABLE CLIENT colours Red 11 Blue 1 Silver 55 Black 61 Beadblast Titanium chairs Chrome 46 Black (matt) 22 Black (textured) 33 glass colours Red 29 Raspberry 83 Violet 28 Purple 16 Blue 72 Teal 17 Green 73 Shocker Yellow 67 Gold XX candy colours Candy Orange 80 Candy Red 29 Candy Raspberry 83 Candy Blue 72 Candy Teal 17 Candy Emerald 70 Candy Green 73 Candy Shocker Yellow 67 Metalic Viper 42 candy colours (special) fluorescent colours Glowing Aura Chameleon Sapphire Racing Raspberry Dazzling Red Fluro Green 89 Fluro Yellow 44 Fluro Orange 71 Fluro Pink 88
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
Stallion Script Form Fixed Frame Adjustable Wheelchair 90100
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This wheelchair has a weight limit of 80kg
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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
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
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
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
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
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
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:
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
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
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 C H U M P - 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:
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
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
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
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
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
Manual Wheelchair Pencoed Technology Park. DEALER Prescription form Pencoed. CF35 5AQ. LPF1U2ULTRALIGHT211113D Tel: Fax:
Invacare Ltd Manual Wheelchair Pencoed Technology Park DEALER Prescription form Pencoed. CF35 5AQ LPF1U2ULTRALIGHT211113D Tel: 01656 776222 Fax: 01656 776220 LPF0020X email: ordersuk@invacare.com January
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
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
BEARINGS BEARINGS
TIRES PNEUMATIC.... 1-4 SNAP ON.....4 PRIMO HIGH PERFORMANCE......5-6 SCHWALBE HIGH PERFORMANCE.....5-6 KENDA HIGH PERFORMANCE... 7 MAINTENANCE FREE TIRES SHOX URETHANE TIRES..... 8 URETHANE TIRES....
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
Additional Front Wheel Options Not Shown FW1 3 x.75 Micro-Caster FW14 4 x.75 Plastic Wheel w/poly Tire FW3 4 x.75 Light-Up Micro-Caster
front wheels FW2 3 x.75 Light-Up Micro-Caster FW23 3 x1.5 Billet Aluminum Micro Caster w/soft Roll Tire FW19 4 x.75 Performance 5 Spoke Billet Aluminum Wheel w/poly Tire - Silver Hub OR Black Hub FW20
SEATING CHOICE TITANIUM FRONT FRAME
Manual Wheelchair Retail Prescription Form Champion140618 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk July 2018 Account No : Contact
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:
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
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:*
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
champion Standard Base Price 1,875 Standard Features
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed. CF35 5AQ LPF1U2CHAMPION290514D Tel: 01656 776222 Fax: 01656 776220 LPF0015Z email: ordersuk@invacare.com January
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
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:
Küschall K Series DEALER Maximum user weight 120kg ( 19 Stone )
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
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 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:
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
champion carbon Customer weight = Kg Code X Description Dealer SEATING CHOICE DDF0204 küschall Champion Carbon 85 Frame Angle
Invacare Ltd Manual Wheelchair Pencoed Technology Park Dealer Prescription Form Pencoed. CF35 5AQ LPF1U2CHAMPION211114D Tel: 01656 776222 Fax: 01656 776220 LPF0015Z email: ordersuk@invacare.com January
k-series Aluminium Standard Features
Manual Wheelchair Retail Prescription Form KSeries200618 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online spares available at: www.invacare.co.uk July 2018 Customer Ref: Account
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:
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
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:
Zippie Zone July 2018 EIRZ1
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UNMATCHED PERFORMANCE. THE PROFESSIONALS BEST CHOICE IN FOLDING ULTRA- LIGHTWEIGHT ABILITY.
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Auftrags-Nr.: Order no.: ... Date Signature. MA 110 Standard
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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
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STELLAR. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.
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Küschall Champion DEALER Maximum user weight 120kg (19 Stone)
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
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
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:
YOU RE YOUNG. YOU RE ACTIVE. YOU RE YOU. GROWTH WITH AN EDGE. ROGUE XP.
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Town: Postal code: Town: Postal code: CLIENT MEASUREMENTS. Seat Width in cm 38 cm 40 cm 42 cm 44 cm 46 cm. 40 cm
Front Castor Seat Depth in cm Deliver to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: E-Mail: E-Mail: Tel: Fax: Tel: Fax: Order date: Purchase order: Number required:
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:*
ORDER FORM Ver.6 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 ZEPHYR EVERY DAY ORDER FORM Ver.6 Rev-091211 DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone: Address: Email: City: State:
Custom Manual Options & ACCESSORIES AUSTRALIA 2013
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Küschall Champion DEALER Maximum user weight 120kg (19 Stone)
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
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
1,795. Base Price. Part no.: CLIENT MEASUREMENTS. Town: Postal code: Town: Postal code: Tel: Fax: Tel: Fax: Purchase order:
Front Castor Seat Depth in cm Deliver to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: E-Mail: E-Mail: Tel: Fax: Tel: Fax: Order date: Purchase order: Number required:
Max. user weight: 110Kg / 140kg USER WEIGHT Fax number: +44 (0)
Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: E-Mail: E-Mail: Tel: Fax: Tel: Fax: Order date: Purchase order: Number required: Marked for: Sunrise order no:
Quickie GTX Swing-Away FSS NET ORDER FORM/PRICE LIST (SIN F-1)
Account No: Drop Ship/Ship To: Date: Name: P.O. #: Address: Buyer: City: State: Marked For: Zip Code: Phone Number: Seat Depth (Continued) 163SD10 17" NC 163SD11 18" NC 163SD12 19" 1 NC Frame Style 163SD13
Quickie 2 January 2014
Mark For: Submitting for: Quote Order Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: ZIP: Dealer Phone: ( ) Fax: ( ) Address: Confirmation Email: Ship To City: ST: ZIP: Confirm
Please check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm
EVO AE Order form Dealer 2017 EVO Dealer: Date: Dealer reference / Client name: Order number: Anglikerstrasse 20 CH-5610 Wohlen Phone: +41 56 618 44 11 Fax: +41 56 618 44 10 e-mail: office@levo.ch configuration
Dealer Please check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm
EVO CEV Order form Dealer 2017 EVO Dealer: Date: Dealer reference / Client name: Order number: Anglikerstrasse 20 CH-5610 Wohlen Phone: +41 56 618 44 11 Fax: +41 56 618 44 10 e-mail: office@levo.ch configuration
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:
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:*
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
Quickie Q7 Adjustable March 2014
Quickie Q7 Adjustable March 2014 EIR4 Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer
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
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.
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
Invoice address: same as company address. Invoice address: other (see below) Cust. no.: Name: Street: Postcode, city: Phone: Fax: Contact:
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 TRAVELER
Order Date: SHIP TO Name: Address: : City: Phone: PRICEE
DEALER Dealer: C O L O U R ECL IPS E Account: P.O.#: Ordered By: Address: City: Phone: Email: Customer Name: Customer Weight: CHAIR INFORMATION ECLIPSE K0005 Adjustable FSH-RSH Capacity 250Lbs NOTE Max.
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
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
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
NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM.
LITTLE WAVE NOT JUST A WHEELCHAIR. A MEMBER OF THE TEAM. EVOLVING AND GROWING WITH YOUR CHILD Seat height, width, depth, CG, caster wing position, seat upholstery, seat pans the most built in adjustment
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
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:*
Quickie 2 EIQ2N Effective April 2011
Quickie 2 EIQ2N Effective April 2011 ACCOUNT #: SHIP TO: DATE: NAME: P.O. #: ADDRESS: BUYER: CITY/ STATE: MARKED FOR: ZIP CODE: PHONE NUMBER: The HCPCS codes provided are based on code verification by
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: ( )
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:
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
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
Quickie 2 AADL - W137
Quickie 2 AADL - W137 EIQ2X, October 2018 Mark For: Submitting for: Quote Order Date: PO#: Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer
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
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
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
Wheelchair Portfolio. Active wheelchair
Wheelchair Portfolio Active wheelchair K-Series Content Frame...2 Backrest...3 Footrest...8 Side guards... 11 Cushions and options... 13 Colours... 14 Front wheels... 16 Rear wheels... 17 Brakes... 25
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:*
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:*
TiLite. Please Fax to the TiLite Customer Service Team at or
- Print as guide for ordering DEALER INFORMATION ler: Adaptive Specialties RTS INFORMATION RTS: Email: SHIP TO INFORMATION Phone: Page 1 of 9 Email: TiLite Information Name: Ship Via: : Please Fax to the
Order Form. English Company stamp
NONO Date User name Company stamp Rigid frame wheelchair Responsible Wheelchair measures Seat width (LS) 24 27 30 33 36 Seat depth (PS) 27,5 30 32,5 35 37,5 40 Seat depth can be increased by 2,5 or 5 cm.
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
Voyager Evo. Rigid-frame active wheelchair. Standard equipment. Canada: Fax: Order Form and Price List
Voyager Evo Rigid-frame active wheelchair Order Form and Price List Canada: 800.665.3327 Fax: 800.463.3659 www.ottobock.ca Provide estimate only Account Information Order Article number: 480A76=00000_K
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.
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
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:*
Order Date : k-series. titanium. Please make your selection with a cross in the box Standard feature Free of Charge
Manual Wheelchair Retail Prescription Form KSeriesTitanium040516 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com July 2016 Online spares available at: www.invacare.co.uk Customer Ref:
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.