Traxx 3 & Atigra 2 Script Form
|
|
|
- Madeleine Jordan
- 6 years ago
- Views:
Transcription
1 Traxx 3 & Atigra 2 Script Form Client Information Address Therapist Information Organisation Phone Height Weight Funding Source Salesperson Information Company Traxx 3 Atigra 2 Standard Features Traxx 3 Atigra 2 Adjustable Seat Width from 410 to 510 Seat Depth Infinite Adjustment from 360 to 510 Detachable T-Armrests, Height and Depth Adjustable Adjustable Seat Tilt (0 to 9 ) & Backrest Recline (90 to 120 ) Swing-away and Detachable Legrests (Standard Footplate) Standard Curved Headrest VR2 60Ah Controller Independent Suspension System 6 or 10km/h 300W Motors with 50Ah Batteries Padded Lap Belt Measurement Guide A (back height) B (arm height) C (lower leg length) D (seat depth) E (chest width) F (seat width) G (height from seat to top of head) H (shoulder width) Page 1 of 5
2 Seat Dimension Seat Width and Depth Width Depth 360 (14 ) 385 (15 ) 410 (16 ) 435 (17 ) 460 (18 ) 385 (19 ) 510 (20 ) 305 (12") 330 (13") 360 (14") 385 (15") 410 (16") 435 (17") 460 (18") 485 (19") 510 (20") Seat-to-Floor Height seat height measured from floor to seat pan at 0 tilt Manual Adjustable Lift (75) Rear seat height enter a figure between 460 and 570 Front seat height enter a figure between 460 and 570 Backrest Angle Manual Adjustable Recline If selected, circle appropriate preset below Power Tilt with COG Shift (0 to 50 ) Power Lift (300) and Tilt (0 to 45 ) Combined with initial height 480 to Power Recliner with Shear Reduction (0 to 80 ) Seat and Backrest Cushion Seat Cushion sizes according to seat frame settings KISS Seat Cushion Lite (75) w/ Metal Seat Pan AC Mobility Padded Seat Bare Seat Frame Backrest Cushion sizes accordinwg to seat frame settings KISS Backrest Cushion Lite and Cushion Contour Without Backrest Cushion Backrest Plate only Without Backrest Cushion Backrest Canes only Page 2 of 5
3 Armrests & Armpads Armrests reclining armrest is recoended while Power Recline is ordered Detachable T-Armrests Height and Depth Adjustable Flip-back Armrest Height Adjustable Flip-back Reclining Armrest Height Adjustable recoended with power recline Armpad Ergo Armpad 300 Padded Armpad 350 Contour Armpad 370 Legrests - Left Hand Side Legrests - Right Hand Side Central Mounted Legrest Central Mounted Legrest Fixed Central Mounted Legrest (85 to 95 ) Swing-away Legrests Fixed Central Mounted Legrest (85 to 95 ) Swing-away Legrests 75 Swing in/swing out Legrest (320 to 460) 90 Straight Legrest (280 to 370) 75 Swing in/swing out Legrest (320 to 460) 90 Straight Legrest (280 to 370) Manual Elevating Legrest (10 to 90 ) Manual Elevating Legrest (10 to 90 ) Power Elevating Legrest (10 to 80 ) Stump Support Power Elevating Legrest (10 to 80 ) Stump Support Page 3 of 7 75 Swing-away Legrest 90 Straight Legrest Manual Elevating Legrest Power Elevating Legrest Page 3 of 5
4 vvv Footplate - Left Hand Side selected only on the swing-away legrests Footplate - Right Hand Side selected only on the swing-away legrests Flip-up Standard Footplate Flip-up Angle and Depth Adjustable Footplate Flip-up Standard Footplate Flip-up Angle and Depth Adjustable Footplate Seat Accessories Headrest One-piece Curved Headrest (250 x 120 ) One-piece Curved Headrest Sideways Adjustable (350 x 120 ) Without Headrest AC Mobility Padded Headrest Flip-back Tube Poel Poel, Small (80 x 80 ) Poel, Large (100 x 100 ) Removable and Drop-down Brackets Positioning Straps No Belt Padded Lap Belt Padded H-Belt Trunk Support - Left Hand Side Lateral Support, Short (120 x 80 ) Lateral Support, Medium (150 x 80 ) Lateral Support, Long (180 x 100 ) Lateral Support, Extra Long (210 x 100 ) Removable and Swing-away Brackets Trunk Support - Right Hand Side Lateral Support, Short (120 x 80 ) Lateral Support, Medium (150 x 80 ) Lateral Support, Long (180 x 100 ) Lateral Support, Extra Long (210 x 100 ) Removable and Swing-away Brackets With 3D Air Mesh Fabric Cover With 3D Air Mesh Fabric Cover Hip Support - Left Hand Side Hip Support - Right Hand Side Hip Support, Short (150 x 80 ) Hip Support, Long (250 x 100 ) Removable Brackets Swing-away Brackets Hip Support, Short (150 x 80 ) Hip Support, Long (250 x 100 ) Removable Brackets Swing-away Brackets Page 4 of 5
5 Power Base Colour Speed Limit Motor Metallic Red Kelvin Blue Silver Black 6 km/h 10 km/h 300W 2-Pole Motor * 2 only available for Atigra 2 450W 4-Pole Motor * 2 available for Atigra 2 and Traxx 3 Controller Controls VR2 Controller Joystick Controller Bracket - Left Hand Side Standard Bracket Parallel Swing away R-Net JSM Control System R-net System is required for over 2 actuators R-Net CJSM Control System with colour screen R-net System is required for over 2 actuators Joystick Controller Bracket - Right Hand Side Standard Bracket Parallel Swing away Joystick Knobs T Shaped Soft Ball Shaped L Shaped Mushroom Shaped Short Shaped Ball Shaped Battery Accessories Charger Without Batteries 50 AH * 2 6A Charger (100~220V) 8A Charger (100~220V) Light Lighting System with Indicators & LED Lighting Transportation Kit 4-Point tie-down Accessories Lap Trap Cane Holder IV Pole Holder Oxygen Tank Holder Cell Phone Holder Tablet Holder Page 5 of 5
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
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
JIVE F/R: 5,650 9,193 JIVE M: 5,895 9,591
Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: Country: Country: Tel: Fax: Tel: Fax: Order date: Marked for: Purchase order: Standard Features Angle adj. footplate
ALEX QLASS. Order form. T: +44 (0) F: +44 (0)
Order form ALEX QLASS T: +44 (0)8450 745 945 F: +44 (0)8450 745 946 mobilityorders@handicare.co.uk www.handicare.co.uk Valid from 1-4-2015 Version 1.0 Dealer Date Reference No. Delivery address Quantity
C300 Corpus Tilt. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * Contact: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the
Orderform UK / IR Valid from Version 2.1. Alex QLASS. Date:
Alex QLASS 1 / 8 0,8 Dealer: Date: Reference No.: Quantity: Delivery address: 6.948 5.559 Basic configuration Excluding VAT - 4mph/6 km/h RWD - Battery charger 8A -24 V - Armrests standard removable -
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
Invacare FOX (Modulite Seating System) Retail Max User Weight 127Kg (20 stone)
Power Wheelchair Retail Prescription Form FOXMOD210917 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk OCTOBER 2017 Customer Ref : Account
Standard Base Price : 2,950. Standard Features
Power Wheelchair Retail Prescription Form PRONTOM41PP010716 Tel: 01656 776222 Fax: 01656 776220 JULY 2016 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
Invacare Storm4 Easy Adapt Retail Max User Weight 150kgs (23.5 stone) Standard Features
Power Wheelchair Retail Prescription Form STORM4EA010117 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2017 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
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
Velocity Order Form. Dealer Information Dealer Name ATP Account Number Phone Fax Date PO# Ship to Address City State Zip
1-800-963-7487 Fax: 239-772-3252 Velocity Order Form Dealer Information Dealer Name ATP Account Number Phone Fax E-Mail Date PO# Ship to Address City State Zip Client Information Weight Height Seat-to-Floor
Bora. Standard Base Price 4,100. Standard Features SEAT DEPTHS
Power Wheelchair Retail Prescription Form BORAMOD121218 Tel: 01656 776222 Fax: 01656 776220 JANUARY 2019 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Customer Ref : Account
Invacare Kite (Max Seating System) Retail Max User Weight 160Kg (25 stone)
Power Wheelchair Retail Prescription Form KITEMAX160718 Tel: 01656 776222 Fax: 01656 776220 JULY 2018 Email: ordersuk@invacare.com Online Spares available at: www.invacare.co.uk Account No : Contact No
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
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
ORDER FORM EIPW25. with CAPTAIN'S SEAT. Print pages 1-10 to exclude pictures. Buyer State Zip
ORDER FORM Print pages 1-10 to exclude pictures. with CAPTAIN'S SEAT EIPW25 Customer Account # Date PO# Ship To Name Address City Buyer State Zip Mark For Phone Client Measurements a) Top of head to seat
Orderform UK / IR Valid from Version 2.1 LUCA QLASS. Date:
LUCA QLASS 1 / 8 0,8 Dealer: Date: Reference No.: Quantity: Delivery address: 4.650 3.720 Basic configuration Excluding VAT - 4mph/6 km/h RWD - Fixed joystick bracket, right hand - PU side cushions - Drive
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
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
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:
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
Quantum 1450 Group 3 Single Power Order Form Up To 600lbs Weight Capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax:
C350 Corpus VR2 Advanced
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
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
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:
Tango. Setting a new standard in powered wheelchairs. Comprehensive standard configuration includes:
Setting a new standard in powered wheelchairs The Quickie Tango is THE complete, flexible and cost-effective indoor/outdoor powered wheelchair solution. Comprehensive standard configuration includes: Powered
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
Canada Quote / Order Form Combi
Canada Quote / Order Form Combi 7105 Northland Terrace Brooklyn Park, MN 55428 Ph# 1-888-538-6872- Ext 2 Fax# 763-582-0442 Amy Jorgensen-Inside Sales AmyJ@danetechnologies.com www.levousa.com Dealer Information
Phone: Nov-17
By Ormesa New 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List in USD Phone: 800-327-0681 Nov-17 Fax: 260-665-3047 Email: iim@mobility-usa.com Quote: P.O. www.mobility-usa.com Bill To
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
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
R82 Stingray - E1233
Account #: Purchase Order No.: Contact: R82 Stingray - E1233 USD Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: US
Setting a new standard in powered wheelchairs
Setting a new standard in powered wheelchairs The Quickie Tango is THE complete, flexible and cost-effective indoor/outdoor powered wheelchair solution. Comprehensive standard configuration includes: Powered
SALSA M. Salsa MWD. Base Price 4,733 STANDARD SEAT: FRAME / SEAT SIZE STANDARD SEAT: CUSHION JAY CUSHIONS JAY COMFORT SEAT
Invoice to: Deliver to: Name: Name: Street: Street: Town: Postal code: Town: Postal code: Country: Country: Tel: Fax: Tel: Fax: Order date: Marked for: Purchase order: SALSA M Max. user weight: 140 kg
JIVE M2 SEDEO ERGO... 5 SHROUDS... 5 CHASSIS... 5 COLOURED SHROUD ELEMENTS... 6 BACK... 37
Title - 1 - Title - 2 - Table Of Contents JIVE M2 SEDEO ERGO... 5 SHROUDS... 5 CHASSIS... 5 COLOURED SHROUD ELEMENTS... 6 BACK... 7 JAY 3 BACK... 9 SEAT... 10 DRIVE WHEEL / CASTOR WHEEL... 11 14 INCH DRIVE
X850 Corpus. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
ULTRA TDX 2. Retail Order Form Max user weight 136kg (21.4 stone) Featuring
TDX 2 ULTRA Retail Order Form Max user weight 136kg (21.4 stone) Featuring lass leading shear reduction C with our ESR Mechanism chieve the perfect fit with simple A and precise adjustment features Maximise
Phone: Jan 17. Fax: usa.com Quote: P.O. usa.com Bill To
By Ormesa New 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 800 327 0681 Jan 17 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility usa.com Bill To Dealer:
C300 TS VR Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
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:
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
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
Specifications are subject to change without notice. 2018, Amylior Inc. (March 2018) AMYSEAT (Rev.0) Page 1 of 7
Page 1 of 7 ACCOUNT INFORMATION P.O. # or Quote: Dealer Contact Name: Email Address: Phone Number: Bill to (Name): Bill to (Location): Ship to (Name): Address: City: State: User Name or Number: User Weight:
Paediatric seating for the Bingo OT. Designed and manufactured by
Designed and manufactured by Paediatric seating for the Bingo OT A breakthrough in rehabilitative stroller seating Introducing the latest innovation from the designers of the revolutionary SPEX seating
Power. Compact yet powerful at home outside as well as inside! Configured Salsa with Comfort Seating and powered elevating legrests
Compact yet powerful at home outside as well as inside! Configured Salsa with Comfort Seating and powered elevating legrests Compact dimensions for indoor mobility Low seat height for easy table access
C350 Corpus VR2 Advanced
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
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
Base configuration Electromagnetic front caster lock Seating position and center of gravity adjustable Comfort armrests
Power wheelchair Swiss VIVA Grand 005.40.4002 9 700.00 Length with/without legrests 98/73 cm Width 63 cm Loading capacity 180 kg Speed 10 km/h q Quotation request q Order Company: Street: Place, post code:
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
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
C350 PS VR2. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
ZIPPIE SALSA R2 - CHASSIS
Title - 1 - Table Of Contents ZIPPIE SALSA R2 / ZIPPIE SALSA M2... 4 FRAME AND BATTERY BOX... 4 ZIPPIE SALSA R2 - CHASSIS... 4 ZIPPIE SALSA M2 - CHASSIS... 5 ZIPPIE SALSA R2 - SEAT HEIGHT EXTENSION KIT...
wheelchairs aspire for... mobility comfort style LITE TRANSIT RANGE Aspire EVOKE Aspire EVOKE HD
EVOKE & EVOKE HD TRANSIT ASSIST wheelchairs aspire for... mobility comfort style LITE LITE TRANSIT RELAX RANGE Aspire EVOKE Aspire EVOKE HD Aspire ASSIST Aspire TRANSIT Aspire RELAX Aspire LITE Aspire
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
The maximum standard user weight capacity is 300 lbs (For Invoicing, if Different then "Ship To" Location)
SAVE RESET EMAIL FORM PRINT November, 204 BILL TO: The maximum standard user weight capacity is 300 lbs (For Invoicing, if Different then "Ship To" Location) SHIP TO: Dealer Name: Dealer Name: Contact:
PRESCRIPTION FORM. Delivery address. Purchase order. Shipment date Delivery Date. Type
PRESCRIPTION FORM Distributor Branch Client Phone Delivery address (Use 'Shift'+'Enter' for new line) Salesperson E-mail Purchase order Type Date Shipment date Delivery Date Important Demo Request Order
Options and Accessories
Options and Accessories LIVE WITHOUT LIMITS 2 JAY COMFORT SEATING...4 JAY CLINICAL CUSHIONS AND BACKS...8 POWER SEATING MODULES... 10 BACKREST RECLINE OPTIONS... 12 ARMRESTS... 13 LEGRESTS... 16 Swing
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:
C300 Corpus VR2. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
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
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
WHEELCHAIR RANGE. aspire for... Comfort Posture Mobility DANISH DESIGN
WHEELCHAIR RANGE aspire for... Comfort Posture Mobility EVOKE REHAB RX ASSIST TRANSIT LITE TRANSIT www.aspirecare.com.au 300 33 0 EVOKE Lightweight & Highly Adjustable The Aspire EVOKE and EVOKE HD are
Vision Ultra-single power
Account # Dealer Name Contact Phone Date Fax E-Mail PO Number Ship to Address City State Zip *HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers
Motability Price List
Motability Price List Q1 January - March 2016 Invacare Ltd Unit 4 Pencoed Technology Park Bridgend CF35 5AQ T: 01656 776222 F: 01656 776220 E: ordersuk@invacare.com www.invacare.co.uk Motability Contents
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)
C500(S) Corpus 3G R-Net
list: 27 Spain EUR Dealer Information Contact: Customer Code: Customer Name: Address 1: City: Post code: Phone: Fax: PO: Client Information First Name: Last Name: Diagnosis: Address 1: Address 2: Postal
x:panda, size 1, med. back X c x:panda, size 1, med. seat 7¼" X c
Account No. Drop Ship: Date: Name P.O. Number: Address Buyer: City Marked For: State Zip E Mail: Tel. Fax Features included in standard price: Height, Depth & Angle Adjustable Back Angle Adjustable Adduction
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
M1 - NPO. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information
* Indicates a Required Field Dealer Information * ATP: Dealer Code: * Dealer Name: Address: * City: * State/Zip: * Phone#: * Fax#: PO#: Email Address: Client Information Permobil recommends that the client
Invacare REA Azalea Transit RETAIL Max User Weight 135Kg (21 stone)
Manual Wheelchair Retail Prescription Form ReaAzaleaTransit281117 Tel: 01656 776222 Fax: 01656 776220 Email: ordersuk@invacare.com January 2018 Online spares available at: www.invacare.co.uk Customer Ref:
Jupiter. Uncompromised comfort and postural support in keeping with a contemporary home setting
Jupiter Uncompromised comfort and postural support in keeping with a contemporary home setting Jupiter Jupiter is the ideal home use chair for children through to adults, that combines comfort with superior
Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:
Quantum 6400Z Series Group 4 Single Power & Multiple Power Order Form 300 lbs. weight capacity Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone:
SHIPPING INFORMATION Provider Acct #: Address: ST: ZIP:
May 2014 Kids FAST Order Form Maximum Weight Capacity 80 lbs. 12"Wx14.5"Dx19.5"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING
SHIPPING INFORMATION. Order
Size 3 Order Form MASS 2014 Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Pride Mobility Products Aust Pty Ltd 20-24 Apollo Drive Hallam VIC 3803 Ph: 03 8770 9600 Fax: 03 9703 2960 Date:
QLASS OPTIONS SAMM / ALEX / LUCA
QLASS OPTIONS SAMM / ALEX / LUCA OPTIONS CONTROLS AND LIGHTING B000156 B000157 B000158 B000714 B000715 Dynamic Shark drive only - Lighting: no - Powered options: no Dynamic Shark lights - Powered options:
BINGO Evolution rehab pushchair
BINGO Evolution rehab pushchair Size 2 for children at the age of approx. 4-10 years Crash tested according to ISO 7176-19 and ANSI/RESNA WC/Vol.1. - Section 19 Order form incl. Exportprices ( ) valid
Page 1 of 13 INTRODUCTION PATIENT INFORMATION
Pride Mobility Products Co. For AADL use only 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Email: productorders@pridemobility.com Q6 Edge HD Order Form with TRU-Balance
FUSION Seating Prescription Form Custom Built Seating System
GENERAL INFORMATION Clinician: Email: Date: Service: Delivery Address: Client Name/Ref: Address/School: Current Equipment: Issues with Current Equipment: Observations, deformity: Hips/Pelvis: Spine/Trunk:
Aquatec. Ocean Family. Flexible, modular shower chair commode solutions
Aquatec Ocean Family Flexible, modular shower chair commode solutions A range of high quality, modular, stainless steel shower chair commodes that are designed to support a wide range of clients and conditions.
WHEELCHAIRS. aspire for... mobility comfort style OUR RANGE The Aspire EVOKE.
EVOKE ASSIST WHEELCHAIRS aspire for... mobility comfort style LITE TRANSIT RELAX OUR RANGE The Aspire EVOKE The Aspire ASSIST The Aspire TRANSIT The Aspire RELAX The Aspire LITE www.aspirewheelchairs.com.au
Accessories brochure
Accessories brochure NEW The Invacare Rea Passive range, with its tilt and recline chairs is compatible with a wide variety of accessories, giving users the opportunity to achieve an optimal fit, and greater
NEMO VERTICAL Authorised client weight 100 kg + 10 kg additional load ISO-CRASH TESTED
NEMO VERTICAL 1.595 Authorised client weight 100 kg + 10 kg additional load ISO-CRASH TESTED Always finding the right position Standing function Lying function High seat width variance The new multifunctional
AT MSRP Price List. Description. HCPCS Code K0020 K0020 K0106 K0106. Part Number AP3 AP4 GAP GAPS 1386/87 FUA PT0031
Client: P.O.#: AT MSRP List AP3 AP4 GAP GAPS 1386/87 FUA PT0031 3 x 12 Desk Length Leatherette 4 x 16 Tapered Leatherette Standard Height Adjustable, Removable Armrest Flip-Up Armrest Left $37.50/ea. $164.00/ea.
Kimba. T h e K i m b a F a m i l y o f P e d i a t r i c M o b i l i t y P r o d u c t s
Kimba T h e K i m b a F a m i l y o f P e d i a t r i c M o b i l i t y P r o d u c t s Great for Kids Easy for Moms, Dads and Caregivers! Finally, a tilt-in-space mobility system that brings it all together.
Positioning Components Order Form - ODJFS Only
Quantum Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 Fax: 866-707-3422 Email: quantumorders@pridemobility.com Positioning Components Order Form - ODJFS Only Account Number: Date: Provider
R82 Wombat Living. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: Date: Wombat Living Standard Features:
Account #: Purchase Order No.: Date: Contact: R82 Wombat Living CAD Retail Price List/ Order Form Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone: Wombat
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:
QUICKIE TANGO... 5 BASE FRAME... 5 BATTERY BOX... 5 COVERS... 6 MAIN FRAME... 7 MOTOR MOUNT & ANTI TIP... 8 SUSPENSION... 9 MOTOR...
Title - 1 - Title - 2 - Table Of Contents QUICKIE TANGO... 5 BASE FRAME... 5 BATTERY BOX... 5 COVERS... 6 MAIN FRAME... 7 MOTOR MOUNT & ANTI TIP... 8 SUSPENSION... 9 MOTORS... 10 MOTOR... 10 SEAT/BACK...
Invacare. Simply the best fit!
Simply the best fit! The revolutionary power wheelchair has been created to satisfy even the most demanding requirements regarding configurability, adaptability and functionality. Not only is it stylish
Client Information and Specifications:
Model: Frontier V6 Hybrid Rear Wheel Drive 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 260 665 2769 Nov 17 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility
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
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
Featuring. Customer Ref: TDX2 Ultra
Featuring Class leading shear reduction with our ESR Mechanism Achieve the perfect fit with simple and precise adjustment features Maximise comfort and pressure relief with the advanced tilt and recline
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
R82 Flamingo Flamingo High-Low
Account #: Purchase Order No.: Contact: R82 Flamingo Flamingo High-Low Retail Price List/ Order Form Date: Mark For: Bill To: Address: City/State/Zip: Phone: Email Ship To: Address: City/State/Zip: Phone:
Multi-Position Standing(MPS) System US PRICE LIST AND ORDER FORM Effective July 1, 2012
Multi-Position Standing(MPS) System US PRICE LIST AND ORDER FORM Effective July 1, 2012 Date of Order: Dealer Name: Dealer Account #: PO #: Base MFR. PO #: Tag: Purchasing Contact: Phone: Fax: RTS/Therapist:
Model: V6 Frontier C73 Compact 201 Growth Parkway Angola, IN Phone: Jan 18. Bill To: Dealer: Contact: Address:
Model: V6 Frontier C73 Compact 201 Growth Parkway Angola, IN 46703 U.S Suggested Retail Price List Phone: 260 665 2769 Jan 18 Fax: 260 665 3047 Email: iim@mobility usa.com Quote: P.O. www.mobility usa.com
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
FITS MY LIFE QM-710 SEDEO ERGO
FITS MY LIFE QM-710 SEDEO ERGO FITS MY LIFE Take your seat and experience the revolution in powered wheelchairs! 2 QM-710 SEDEO ERGO The QM-710 Sedeo Ergo featuring Spidertrac 2.0 suspension, redefines
LIVE OUT QUICKIE QM-7 LIMITS WITH EXPERIENCE IT ALL. SEDEO Ergo Seating
EXPERIENCE IT ALL The QUICKIE QM-7 with SEDEO Ergo Seating and SpiderTrac 2.0 suspension redefines powered wheelchair technology, inside and out. Travel further, take on new challenges, and be your independent