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 No: Delivery Address: Account No: Order No: Order Qty: x Order Date: Please make your selection with a cross in the box Standard feature Free of charge (NC:9999) Non-compatability Customer weight = Kg Code Description NC's (Non Conformance) Retail MODEL CKG0004 X ACTION 4 NG HEAVY DUTY 160 KG 618 CKGSPEC ACTION 4NG HD Special Basic Model - PLEASE COMPLETE DETAILS AT THE END OF THE FORM PROPULSION TYPE CKG0100 SELF PROPULSION (NC : 1000, 1010) CKG0110 SEAT SEAT WIDTH TRANSIT PROPULSION (ONLY AVAILABLE WITH FIXED REAR WHEEL AXLE AND FOOT OPERATED BRAKE) (NC : 0930, 0950, 0980, 1020, 1030, 1050, 1060, 1110, 1125, 1220) CKG0170 505MM SEAT WIDTH (20") (INCLUDING BACK BRACE) (NC : 0292) CKG0171 CKG0172 SEAT DEPTH 555MM SEAT WIDTH (22") (INCLUDING REINFORCED SEAT UPHOLSTERY, ADJ. HEEL STRAP & BACK BRACE) 605MM SEAT WIDTH (24") (INCLUDING REINFORCED SEAT UPHOLSTERY, ADJ. HEEL STRAP & BACK BRACE) (NC : 0280) (NC : 0180, 0280) CKG0180 400MM SEAT DEPTH (16") (NC : 0292, 0702, 0703) CKG0190 450MM SEAT DEPTH (18") (NC: 0701, 0703) CKG0195 500MM SEAT DEPTH (20") (NC : 0280, 0295) CKG0200 400MM TO 450MM ADJUSTABLE SEAT DEPTH (16" - 18") (NC : 0280, 0292, 0295) 17 SEAT HEIGHT CKG0210 510MM SEAT HEIGHT (20") (NC : 0980) CKG0220 485MM SEAT HEIGHT (19") CKG0230 460MM SEAT HEIGHT (18") SEAT UPHOLSTERY TYPE Standard Features Self or Transit Propulsion Choice of 3 Seat Widths 505mm to 605mm (20" -24") Choice of 3 Seat Depths 400mm to 500mm (16" -20") Choice of 3 Seat Heights 460mm to 510mm (18" -20") Nylon Seat Upholstery Fixed 7º 380mm Backrest Standard Padded Nylon Sling Type Backrest Upholstery 80º Swing In/Swing Out Legrest Hangers Flip Up Footplates Removable, Depth and Height Adjustable 'Rio' Desk Arm Armrests Choice of 5 Colours Push or Pull to lock brakes (configuration dependant) Transportation Kit and Buckle Belt Adjustable heel straps User tool kit Standard Base Price: 618 Invacare Action 4 NG Heavy Duty Version Retail Max User Weight 160Kg (25 stone) * Configurations may vary to the image shown CUSTOMISE COLOUR (SEE OPTION 0821) CKG0280 NYLON WITHOUT VELCRO STRIPS SEAT UPHOLSTERY CKG0290 NYLON WITH VELCRO STRIPS SEAT UPHOLSTERY CKG0292 SPECIAL HEAVY DUTY SEAT UPHOLSTERY TENSION & DEPTH ADJUSTABLE 163 CKG0295 PADDED NYLON SEAT UPHOLSTERY Page 1 of 5
BACKREST BACKREST TYPE Anti-tippers required with reclining backrest 0333) CKG0300 CKG0333 FIXED 7 BACKREST HEIGHT ADJUST 380 TO 460MM (DELIVERED 380MM) FIXED PUSH HANDLES (follow upholstery height) RECLINING (GAS SPRING) 0/30) BACKREST (incl backbrace & only passive rear wheel pos.) 3 HEIGHTS 390/410/430MM (DELIVERED 430MM) FIXED PUSH HANDLES (NC : 0365, 0369, 0716, 0717, 0718, SWO0001) (NC : 0360, 1060, SWO0001) 200 CKG0341 FOLDING BACKREST 430MM HEIGHT FIXED PUSH HANDLES (NC : 0360) BACKREST UPHOLSTERY TYPE CKG0350 WITHOUT BACKREST UPHOLSTERY CKG0360 BASIC PADDED NYLON SLING TYPE (JEMIMA) CKG0365 LOMBAR SUPPORT (+1 STRAP) PADDED COVER 12 CKG0369 CONTOUR ADJUSTABLE (HALF TENSION ADJUSTABLE, 3+1 STRAPS) PADDED COVER (INCLUDING BACK BRACE) 27 CKG0370 CONTOUR ADJUSTABLE (FULL TENSION ADJUSTABLE, 7+1 STRAPS) PADDED COVER (INCLUDING BACK BRACE) 103 HANGERS/FOOTPLATES HANGERS RH TYPE CKG0390 80 STRAIGHT RH SWING IN/SWING OUT HANGER CKG0400 ELEVATING LEGREST (0 TO 80 ) RH SWING IN/SWING OUT HANGER (INCLUDING CALFPAD) (NC: 0480, 0491, 0760, 0770) 90 CKG0420 AMPUTEE LEGREST RH (NC: 0480, 0490, 0491, 0760) 114 HANGERS LH TYPE CKG0440 80 STRAIGHT LH SWING IN/SWING OUT HANGER CKG0450 ELEVATING LEGREST (0 TO 80 ) LH SWING IN/SWING OUT HANGER (INCLUDING CALFPAD) (NC: 0491, 0500, 0760, 0770) 90 CKG0470 AMPUTEE LEGREST LH (NC: 0491, 0500, 0510, 0760) 114 FOOTPLATES RH TYPE CKG0480 FLIP UP RH FOOTPLATE CKG0490 FLIP UP DEPTH & ANGLE AJUSTABLE RH FOOTPLATE (NC : 0770) 37 CKG0491 ONE PIECE FOOTPLATE DEPTH & ANGLE ADJUSTABLE (NC: 0510, 0770) 67 FOOTPLATES LH TYPE CKG0500 FLIP UP LH FOOTPLATE CKG0510 FLIP UP DEPTH & ANGLE AJUSTABLE LH FOOTPLATE (NC: 0770) 37 ARMRESTS ARMRESTS RH FORM REMOVABLE RH "RIO"(N 1) DESK ADJ. 200-230-260-280MM HEIGHT + CKG0520 SKIRTGUARD ADJ IN DEPTH AND IN HEIGHT. Autolock safety device included. REMOVABLE RH "COMFORT"(N 4) DESK ADJ. IN HEIGHT + SKIRTGUARD CKG0533 ADJ IN HEIGHT. Autolock safety device included. CKG0536 ARMRESTS LH FORM CKG0580 CKG0593 CKG0596 SEAT CUSHION TYPE REMOVABLE RH "COMFORT" (N 4) FULL LENGTH ADJ. IN HEIGHT & DEPTH + SKIRTGUARD ADJ IN HEIGHT. Autolock safety device included. REMOVABLE LH "RIO"(N 1) DESK ADJ. 200-230-260-280MM HEIGHT + SKIRTGUARD ADJ IN DEPTH AND IN HEIGHT. Autolock safety device included. REMOVABLE LH "COMFORT"(N 4) DESK ADJ. IN HEIGHT + SKIRTGUARD ADJ IN HEIGHT. Autolock safety device included. REMOVABLE LH "COMFORT" (N 4) FULL LENGTH ADJ. IN HEIGHT & DEPTH + SKIRTGUARD ADJ IN HEIGHT. Autolock safety device included. (NC : 0593, 0596) (NC : 0580) 28 (NC : 0580) 28 CKG0654 BASIC 50MM FOAM CUSHION 20 SEAT CUSHION DEPTH CKG0701 400MM SEAT DEPTH CKG0702 450MM SEAT DEPTH CKG0703 500MM SEAT DEPTH OTHER SEATING OPTIONS CKG0716 NECKREST, DARTEX (INCLUDING BACKBRACE) (NC : 0717, 0718) 113 CKG0717 HEADREST, DARTEX (INCLUDING BACKBRACE) SIDEWAYS ADJUSTABLE (NC : 0718) 136 CKG0718 HEADREST WITH CHEEK SUPPORT, DARTEX (INCLUDING BACKBRACE) SIDEWAYS ADJUSTABLE 157 SWO0001 MULTI ADJUSTABLE SWING AWAY LATERAL SUPPORTS (PAIR). IMPORTANT NOTE: THIS OPTION IS ONLY AVAILABLE AS A SPECIAL ORDER. LEAD TIME 2-3 WEEKS. ONLY AVAILABLE WITH BACKREST OPTION 0341. 244 CKG0760 ADJUSTABLE CALF STRAP CKG0770 LONGER FOOTREST TUBE (KNEE TO HEEL 450-530 MM) 25 28 28 Page 2 of 5
COLOURS CKG0800 DARK RED CKG0801 SLATE GREY CKG0803 OCEAN BLUE CKG0804 PEARL WHITE CKG0806 ELECTRIC GREEN CKG0820 ANTHRACITE BLACK CKG0821 SPECIAL COLOUR (ON DEMAND ONLY - 2 WEEK LEAD TIME) 119 FRONT WHEELS CKG0850 200MM x 35MM (8" x 1.1/4") SOLID TYRE CKG0860 200MM x 50MM (8" X 2") PNEUMATIC TYRE 23 CKG0870 200MM x 50MM (8" x 2") SOLID TYRE 23 REAR WHEELS REAR WHEEL TYPE CKG0930 600MM x 35MM (24" x 1.3/8") PNEUMATIC TYRE SPOKED RIM CKG0950 600MM x 35MM (24" x 1.3/8") SOLID TYRE SPOKED RIM 17 CKG0980 550MM x 35MM (22" x 1.3/8") PNEUMATIC TYRE SPOKED RIM (NC : 1110) CKG1000 300MM x 50MM (12" x 2") PNEUMATIC TYRE PLASTIC RIM (NC : 1020, 1030, 1050, 1060, 1110, 1210, 1220) CKG1010 300MM x 50MM (12" x 2") SOLID TYRE PLASTIC RIM (NC : 1020, 1030, 1050, 1060, 1110, 1210, 1220) 31 HANDRIM TYPE CKG1020 ALUMINIUM PRE-ANODIZED HANDRIM CKG1030 HANDRIM COATED IN BLACK ANTI-SLIP PLASTIC (NC : 1130) 29 REAR WHEELS AXLE TYPE CKG1040 FIXED AXLE CKG1050 QUICK RELEASE AXLE REAR WHEELS POSITION CKG1060 STANDARD REAR WHEELS POSITION (AXLE 35MM IN FRONT OF BACKPOST) CKG1070 PASSIVE REAR WHEELS POSITION (AXLE 35MM BEHIND BACKPOST) PUMP CKG1090 PUMP AND SUPPORT 6 CHASSIS OPTIONS TYPE CKG1110 SPOKE PROTECTORS PAIR 67 BRAKES TYPE - NOTE: A brake option MUST be selected CKG1120 PUSH TO LOCK BRAKES CKG1125 PULL TO LOCK BRAKES CKG1130 ATTENDANT HUB BRAKES (INCLUDING PUSH TO LOCK BRAKES) AVAILABLE WITH SOLID TRANSIT REAR WHEELS 180 SAFETY OPTIONS TYPE CKG1175 X TRANSPORTATION KIT (INCLUDING BUCKLE BELT) CKG1189 CKG1192 HIP BELT, 2PT, CTR-PULL PB - M X 460MM PADS, FLAT MOUNT (NOT CRASH TESTED) HIP BELT, 2PT, CTR-PULL PB - L X 620MM PADS, FLAT MOUNT (NOT CRASH TESTED) (NC: 1192) 69 CKG1196 REAR ANTI-TIPPER (PAIR) (NC : 1200, 1245, 1246) 31 CKG1200 REAR ANTI-TIPPERS PAIR WITH TIPPING AID (NC : 1245, 1246) 62 CKG1210 REFLECTORS KIT (FOR SPOKED WHEELS ONLY) 6 CKG1220 BRAKE EXTENSION PAIR 12 ATTENDANT OPTIONS TYPE CKG1240 CANE HOLDER 17 CKG1245 TIPPING AID (RH) 12 CKG1246 TIPPING AID (LH) 12 Total Price: 69 Page 3 of 5
Non Conforming Options: CKG0180 40 CM SEAT DEPTH (16") CKG0280 NYLON WITHOUT VELCRO STRIPS SEAT UPHOLSTERY CKG0292 SPECIAL HEAVY DUTY SEAT UPHOLSTERY TENSION & DEPTH ADJUSTABLE CKG0295 PADDED NYLON SEAT UPHOLSTERY CKG0360 STANDARD PADDED NYLON SLING TYPE (JEMIMA) CKG0364 LOMBAR SUPPORT (+1 STRAP) BI MATERIAL PADDED COVER INCL. BACK POCKET CKG0365 LUMBAR SUPPORT PADDED, SHAPED COVER CKG0368 CONTOUR ADJUSTABLE (HALF TENSION ADJUSTABLE, 3+1 STRAPS) BI MATERIAL PADDED COVER INCL. BACK POCKET (INCLUDING BACK BRACE) CKG0369 CONTOUR (TENSION) ADJUSTABLE PADDED, SHAPED COVER INCLUDING BACK BRACE CKG0375 CONTOUR ADJUSTABLE (FULL TENSION ADJUSTABLE, 7+1 STRAPS) BI MATERIAL PADDED COVER INCL. BACK POCKET (INCLUDING BACK BRACE) CKG0480 CKG0490 CKG0491 CKG0500 CKG0510 CKG0580 CKG0593 CKG0716 CKG0717 CKG0718 CKG0760 CKG0770 CKG0930 CKG0950 CKG0980 CKG1000 CKG1010 CKG1020 CKG1030 CKG1040 CKG1050 CKG1060 CKG1110 CKG1125 CKG1130 CKG1190 CKG1220 CKG1245 CKG1246 FLIP UP RH FOOTPLATE FLIP UP DEPTH & ANGLE AJUSTABLE RH FOOTPLATE ONE PIECE FOOTPLATE DEPTH & ANGLE ADJUSTABLE FLIP UP LH FOOTPLATE FLIP UP DEPTH & ANGLE AJUSTABLE LH FOOTPLATE REMOVABLE LH "RIO"(N 1) DESK ADJ. 20-23-26-28 CM HEIGHT + SKIRTGUARD ADJ IN DEPTH AND IN HEIGHT REMOVABLE LH "COMFORT"(N 4) DESK ADJ. IN HEIGHT + SKIRTGUARD ADJ IN HEIGHT NECKREST, DARTEX (INCLUDING BACKBRACE) HEADREST, DARTEX (INCLUDING BACKBRACE) SIDEWAYS ADJUSTABLE HEADREST WITH CHEEK SUPPORT, DARTEX (INCLUDING BACKBRACE) SIDEWAYS ADJUSTABLE ADJUSTABLE CALF STRAP LONGER FOOTREST TUBE 24" x 1.3/8" PNEUMATIC TYRE SPOKED RIM 24" x 1.3/8" SOLID TYRE SPOKED RIM 22" x 1.3/8" PNEUMATIC TYRE SPOKED RIM 12" x 2" PNEUMATIC TYRE PLASTIC RIM 12" x 2" SOLID TYRE PLASTIC RIM ALUMINIUM PRE-ANODIZED HANDRIM HANDRIM COATED IN BLACK ANTI-SLIP PLASTIC FIXED AXLE QUICK RELEASE AXLE STANDARD REAR WHEELS POSITION SPOKE PROTECTORS PAIR PULL TO LOCK BRAKES ATTENDANT HUB BRAKES (INCLUDING PUSH TO LOCK BRAKES) BUCKLE BELT BRAKE EXTENSION PAIR TIPPING AID (RH) TIPPING AID (LH) Page 4 of 5
Please referto our Invacare Unique special order form, for more complex custom requirements. Available at www.invacare.co.uk Special Instructions -Please supply the following information: Name: Phone: Email: Fax: Description of special request (please include relevant option code or part number): Page 5 of 5