Phone: Nov-17

Similar documents
Phone: Jan 17. Fax: usa.com Quote: P.O. usa.com Bill To

Convaid Trekker 2 - HCPCS E1234 Retail Price List / Order Form

Convaid Trekker 2 - HCPCS E1234 Canadian Retail Price List / Order Form

R82 Stingray - E1233

R82 x:panda. USD Retail Price List/ Order Form. Account #: Purchase Order No.:

R82 Stingray. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: City/State/Zip: Effective: 2/01/ Rev 7.

R82 x:panda. USD Retail Price List/ Order Form. Account #: Purchase Order No.:

R82 Kudu - E1233. Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features: Recline No HCPCS Code Assigned to Kudu sz 4

R82 Kudu - E1233. Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features: Recline No HCPCS Code Assigned to Kudu sz 4

modular seating system with included tilting

C300 Corpus Tilt. Please send order/quote to fax#: (800) to: * Indicates a Required Field Dealer Information

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.

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.

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.

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.

Paediatric seating for the Bingo OT. Designed and manufactured by

R82 Kudu - E1233. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: Kudu Standard Features:

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) Freedom 2 Kids

[ ] Quote [ ] Order. Junior US Retail Price List. Account Information. Ship To Information. Standard Features.

Traxx 3 & Atigra 2 Script Form

SHIPPING INFORMATION Provider Acct #:

BINGO Evolution rehab pushchair

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

x:panda, size 1, med. back X c x:panda, size 1, med. seat 7¼" X c

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

SHIPPING INFORMATION Provider Acct #:

BENTLEY. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.

STELLAR. 15" Seat Width 18" Seat Width. Requires Heavy Duty Base and Seat Frame. Extended delivery lead times may apply.

R82 Wombat Living. CAD Retail Price List/ Order Form. Account #: Purchase Order No.: Date: Wombat Living Standard Features:

Velocity Order Form. Dealer Information Dealer Name ATP Account Number Phone Fax Date PO# Ship to Address City State Zip

M1 - NPO. Dealer Information. Client Information. Client Measurements

SHIPPING INFORMATION. Order

R82 Flamingo Flamingo High-Low

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.

SHIPPING INFORMATION Provider Acct #: Address: ST: ZIP:

Canada Quote / Order Form Combi

NXT Pediatric. Manual Wheelchair. Transport Optional Base

Walkmühlenstraße 1 D Bremervörde Germany Phone: +49 (0) / or -66 Fax: +49 (0) /

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) PRO-CG. Adult Manual Wheelchair

R82 Caribou - E0641. Retail Price List/ Order Form. Account #: Purchase Order No.: Date: Caribou Standard Features:

R82 Rabbit Up - E0638 / E0642 USD Retail Price List/ Order Form

FUZE T50. Order Form USA. Please send your completed order form by to or by fax to

Technical Manual. Swifty The rehabilitation buggy. Models Accessories

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG. Adult Manual Wheelchair

Rehab strollers. for children with special needs

Mygo Seat Spare Parts Catalogue

R82 Caribou - E0641. USD Retail Price List/ Order Form. Account #: Purchase Order No.:

Frame. Pos Item number Description Comment

Quickie IRIS January 2014

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

Basic price 2.250,- Excl. VAT

2241 N Madera Rd Simi Valley, CA Phone: (800) Fax: (888) P.R.O. CG

Innovative and modern rehab pushchair. Designed and hand built in Germany.

EASyS Modular. Technical Manual. EASyS Modular Rehab stroller. Models. Accessories for EASyS Modular seat unit. Accessories for A and Q chassis

Positioning Components Order Form - ODJFS Only

Technical Manual. Thevo The perception seat for dynamic seating. Models. Accessories ThevoTwist. Accessories A chassis

PRESCRIPTION FORM. Delivery address. Purchase order. Shipment date Delivery Date. Type

Convaid, the company that invented the adaptive assisted wheelchair, has helped special

AT MSRP Price List. Description. HCPCS Code K0020 K0020 K0106 K0106. Part Number AP3 AP4 GAP GAPS 1386/87 FUA PT0031

Paediatric Products. Testimonials

Quickie IRIS FSS Net Order Form/Price List (SIN F-1)

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

Invacare EXPRESS Manual Wheelchair Order Form Suggested Canadian Price List Effective October 30th, 2018

VERSATILE durable. soft to the touch. 3-year Manufacturer s Warranty

Accessories brochure

Miko. Wheelbases For Special Seating. Dimensions and Specifications. Buggy & R ough T errain

ATP MOBILITY ASSESSMENT FORM

EASyS seating system - Ergonomic Adjustment and Safety System

Jupiter. Uncompromised comfort and postural support in keeping with a contemporary home setting

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.

Invacare Kite (Modulite Flex3 Seating System) Dealer Max User Weight 160Kg (25 stone)

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

Tilt in space up to 60 degrees Comfort seating Max. user weight: 113kg. Height adjustable folding back Heavy Duty version 158kg

Convaid, the company that invented the adaptive assisted wheelchair, has helped special

18 Wide. MRI Transport Wheelchairs. Overall Width: 26 Wheelchair, With Fixed Footrest. Specifications:

Technical Manual. Swifty - The rehabilitation buggy. Model. Positioning supports & harnesses. Safety & protection

The order form has (MSRP) retail prices, but your price is at least 25% less than retail price. Multiply retail by.75 or call or for a quote.

MEDIchair Northern BC nd Avenue Prince George, British Columbia V2L 3A6 Toll Free

Multi-Positioning Seat (MPS)

The alternative to being bedridden

Account Number: Provider Name: Contact Name: Phone #: Fax #: Address: Taken By: Client Height: Client Weight:

Orderform UK / IR Valid from Version 2.1. Alex QLASS. Date:

This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. AADL CAT # 151.

C300 Corpus VR2. Price list: 27 Spain EUR. Dealer Information. Client Information. Client Measurements

Standard Base Price : 2,950. Standard Features

Invacare REA Azalea Transit RETAIL Max User Weight 135Kg (21 stone)

q Little Wave Flip XP - Rigid Base KF-XPRIGID $

Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA Sales: Phone: (866) Fax: (866)

ORDER FORM EIPW25. with CAPTAIN'S SEAT. Print pages 1-10 to exclude pictures. Buyer State Zip

Invacare Action 3 NG Transit Retail Max User Weight 125Kg (19.7 stone)

Invacare Action 3 Junior Large Retail Max User Weight 80Kg (12.5 stone) Standard Base Price: 539 * Configurations may vary to the image shown

Aquatec. Ocean Family. Flexible, modular shower chair commode solutions

Synthesis Tilt Recliner Model: V4

Vision Ultra-single power

Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.

4.2 HELIO KIDS MODEL. Ultralight Folding Carbon Fiber HELIO KIDS Wheelchair Including angle & depth adjustable back (79 kg lbs weight capacity)

Note Section. Set-to-Spec. This section must be filled out, otherwise the selection will default to the mid-range measurements.

Manufacturer: Model: Seat width: cm Seat depth: cm

Dealer Please check the correct box according to the measured hip width in a sitting position: 35 cm 48 cm

Transcription:

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 Dealer: Contact: Address: City: State: Zip: Phone: Fax: Email: Mark For: Ship To Same as Bill To Dealer: Contact: Address: City: State: Zip: Phone: Fax: Email: Mark For: New Bug Features and Specifications Seat - can be used as a floor sitter, width and depth adjustable by 4" in each direction, small (1/2) can be forward or reverse facing Tilt & Recline - incorporated in the seat 40, easily adjusts with levers located on seat back Headrest - incorporated into the backrest so that the child always has a support Backrest - slightly contoured, can recline 40 (hinge coincides with child's center of gravity) height adjustable 4" with slots for accessories Elevating Legrest - push button adjustable, footrest is height and angle adjustable Stroller Frame - bronze powder coated aluminum with an angle adjustable push-handle New BUG Seat - includes: seat back, seat pan, tilt, and recline. NBS New BUG Small $1,500.00 E1399 NBS3 New BUG Medium $1,600.00 E1399 Base Options NB869-1 4-Wheel Base Sm $1,900.00 E1238 NB869-3 4-Wheel Base Md $2,000.00 E1238 891 Set of Tie Down Hooks (Only available with NB869) $275.00 K0108 Intended for forward-facing transport of the pushchair in a motor vehicle. Conforms with ISO 7176/19 and ANSI RESNA WC/19. NB901-1 3-Wheel Base Sm $2,100.00 E1238 NB901-3 3-Wheel Base Md $2,200.00 E1238 NB856-1 Hi-Low Feeding Base Sm $1,850.00 E1399 NB856-3 Hi-Low Feeding Base Md $1,950.00 E1399

Colors This price is only valid when purchasing a seat unit. Part Number Description Price NBOR-1/NBOR-3 Orange $10.00 NBBL-1/NBBL-3 Blue $10.00 NBPK-1/NBPK-3 Pink $10.00 Footrest Options Footplate and Hardware Required Parts NB810-1 Angle Adjustable Flip Up Footplate Sm requires NB810-HW $125.00 K0040 NB810-3 Angle Adjustable Flip Up Footplate Md requires NB810-HW $125.00 K0040 NB810-HW Footplate Hardware and Adjustment Tool $125.00 E1028 Footrest Accessories NB811 Calf Strap $50.00 E0995 827 Foot Strap 8-11" $70.00 E0951 827A Foot Strap 11-14" $80.00 E0951 NB892-1/2 Padded Foot Plate Sm $100.00 K0108 NB892-3/4 Padded Foot Plate Md $100.00 K0108 Hip Guide Options Hip Guides and Hardware Required Parts Size Small Left Hip Guide width & angle adj armrest & upholstery NB815-L-1 requires NB815-HW Right Hip Guide width & angle adj armrest & upholstery $60.00 E0956 NB815-R-1 requires NB815-HW $60.00 E0956 NB815-L-HW/R- HW Hardware for Hip Guide and Arm Rest $60.00 E1028 Size Medium Left Hip Guide width & angle adj armrest & upholstery NB815-L-3 requires NB815-HW Right Hip Guide width & angle adj armrest & upholstery $60.00 E0956 NB815-R-3 requires NB815-HW $60.00 E0956 NB815-L-HW/R- HW Hardware for Hip Guide and Arm Rest $60.00 E1028 Positioning Options 817-1 Leg Straps Sm $135.00 K0038 817-3 Leg Straps Md $135.00 K0038 Page 2/5

Positioning Options Continued NB920-1/2 4 Point Pelvic Belt Sm $195.00 E0978 NB920-3/4 4 Point Pelvic Belt Md $195.00 E0978 894-1 45 Pelvic Belt Sm $95.00 E0978 894-3 45 Pelvic Belt Md $95.00 E0978 828-1/2 Chest Belt Sm $85.00 E0960 828-3/4 Chest Belt Md $85.00 E0960 906-1 5 Point Harness Sm $130.00 E0960 906-4 5 Point Harness Md $130.00 E0960 NB903-1 5 Point Vest Harness Sm $295.00 E0960 NB903-3 5 Point Vest Harness Md $295.00 E0960 853 Vest Harness Sm $175.00 E0960 853-3 Vest Harness Md $175.00 E0960 NB868-1 Wrappable and Flexible Trunk Supports Sm $430.00 E0956 height and depth adjustable NB868-3 Wrappable and Flexible Truck Supports Md $430.00 E0956 height and depth adjustable HB435-532-B1 Body Point X Small 4 Point Hip Belt WC19 Compliant $97.00 E0978 - size 9" - 11" SH260X5-B1 Body Point X Small Pivot Fit Shoulder Harness WC19 Compliant $122.00 E0960 - size 9" - 11" NB838-1 Lateral Pads Sm requires NB838-HW $100.00 E0956 NB838-3 Lateral Pads Md requires NB838-HW $100.00 E0956 NB838-HW Lateral Hardware - height and depth adjustable $150.00 E1028 NB834-1 Padded Abduction Block with Hardware Sm - depth adjustable $140.00 E0957 NB834-3 Padded Abduction Block with Hardware Md - depth adjustable $140.00 E0957 NB852-1 Headrest w/ Parietal Supports Sm - fixed, height adjustable $290.00 E0955 NB852-3 Headrest w/ Parietal Supports Md - fixed, height adjustable $290.00 E0955 NB863-1 Headrest w/ Occipital-Parietal Supports Sm requires NB863-HW $290.00 E0955 NB863-3 Headrest w/ Occipital-Parietal Supports Md requires NB863-HW $290.00 E0955 NB863-HW Multi Axis Hardware - angle and depth adjustable $265.00 E1028 NB934. Suspension Headrest Attachment - angle and depth adjustable requires NB863 & NB 863-HW $65.00 E1028 Page 3/5

Accessories NB854-BL Blue Shade Umbrella $140.00 K0108 NB854-BLA Black Shade Umbrella $140.00 K0108 NB854-OR Orange Shade Umbrella $140.00 K0108 NB854-YL Yellow Shade Umbrella $140.00 K0108 NB854-PK Pink Shade Umbrella $140.00 K0108 NB819-1 Retractable Canopy Sm front and rear view window requires NB819-HW $295.00 K0108 Retractable Canopy Md front and rear view window NB819-3 requires NB819-HW $295.00 K0108 NB819-HW Canopy Hardware $95.00 E1028 NB825-1 Rain Cover Sm requires NB819 $140.00 K0108 NB825-3 Rain Cover Md requires NB819 $140.00 K0108 NB824-1 Transparent Table with Edge & Hollow Sm requires NB824-HW $240.00 E0950 NB824-3 Transparent Table with Edge & Hollow Md requires NB824-HW $240.00 E0950 NB824-HW Adjustable and Removable Table Hardware $100.00 E1028 NB839-1 Front Handle Sm $200.00 K0108 NB839-3 Front Handle Md $200.00 K0108 818 Thermal Cover Sm $365.00 K0108 818-3 Thermal Cover Md $365.00 K0108 858 Medical Necessity Basket - Not compatible with NB927 or NB935 $125.00 K0108 NB927-1 Vent Tray Sm - Not compatible with 858 $650.00 E1029 NB927-3 Vent Tray Md - Not compatible with 858 $650.00 E1029 NB922 Water Bottle Holder $45.00 K0108 NB935 Oxygen Bottle Holder - Not compatible with 858 $250.00 E2208 NB-IV IV Pole $495.00 K0108 Page 4/5

Client Measurements: A Back height: F Lower leg length: B Chest depth: G Head height: C Chest width: H Arm height: D Seat depth: Age: E Seat width: Weight: DIMENSIONS 4 wheel base 3 wheel base 4 wheel base with seat Note: All specification and prices are subject to change without notice. Prices listed are only valid if ordering with a unit. The HCPCS codes provided are not intended to be billing or legal advice, rather Innovation In Motion's interpretation of the code definitions. Use of the codes provided does not ensure coverage or payment for the item. For coverage information, verify the policy of the appropriate payer. It is recommended to contact Innovation In Motion with any questions regarding proper ordering of the chair at 1-260-665-2769. Page 5/5