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 No : Contact No : Order No : Delivery Address : Order Qty : Order Date : Invacare Storm4 Easy Adapt Retail Max User Weight 150kgs (23.5 stone) Standard Features Easy Adapt Seating Seat width 380mm 530mm Seat depth 380mm 530mm Fixed Armrests with standrad Armpads Manual Tilt N Space Multi Adjustable Legrests Advanced Control System with standard bracket 6km/h (4mph) motor 70Ah (Gel) Batteries Anti Tippers Suspension 8A (200 250V) Charger Standard Base Price 6,102 X Please make your selection with a cross in the box Standard feature Free of Charge Code Description Retail ATC0000 Storm4 Basic Model ATZ0000 Storm4 Special Basic Model - PLEASE COMPLETE DETAILS AT THE END OF THE FORM POA SEATING TYPE ATC1180 X Easy-Adapt Seat Unit 6,102 SEAT WIDTH ATC0352 X Seat width 380mm to 530mm adjustable (15" - 21") SEAT CUSHION (width x depth ) (Flo-tech shape) (Seat depth measured from front end seat plate to backrest cushion) ATC1970 Seat Cushion Easy Adapt 380mm x 410mm (15" x 16") Not available with Tension adjustable Back ATC1971 Seat Cushion Easy Adapt 380mm x 460mm (15" x 18") Not available with Tension adjustable Back ATC1972 Seat Cushion Easy Adapt 380mm x 510mm (15" x 20") Not available with Tension adjustable Back, ATC1973 Seat Cushion Easy Adapt 430mm x 410mm (17" x 16") Not available with Tension adjustable Back ATC1974 Seat Cushion Easy Adapt 430mm x 460mm (17" x 18") Not available with Tension adjustable back 530mm ATC1975 Seat Cushion Easy Adapt 430mm x 510mm (17" x 20") Not available with Tension adjustable back 530mm ATC1976 Seat Cushion Easy Adapt 480mm x 410mm (19" x 16") Not available with Tension adjustable back 530mm ATC1977 Seat Cushion Easy Adapt 480mm x 460mm (19" x 18") Not available with Tension adjustable back 530mm ATC1978 Seat Cushion Easy Adapt 480mm x 510mm (19" x 20") Not available with Tension adjustable back 530mm ATC1979 Seat Cushion Easy Adapt 530mm x 430mm (21" x 17") ATC1980 Seat Cushion Easy Adapt 530mm x 460mm (21" x 18") ATC1981 Seat Cushion Easy Adapt 530mm x 510mm (21" x 20") ATC1120 Without Seat Cushion (* Seat depth range must be chosen below) Page 1 of 5
BACK CUSHION (width x height) ATC1985 Easy Adapt Back Cushion 380mm (370mm x 550mm) Not available with Push bar, Trunk Supports ATC1986 Easy Adapt Back Cushion 430mm (400mm x 550mm) ATC1987 Easy Adapt Back Cushion 480mm (450mm x 550mm) ATC1988 Easy Adapt Back Cushion 530mm (490mm x 550mm) ATC1185 Tension adjustable Sling Back (430mm wide), black nylon Not available with Push bar, Trunk Supports 295 ATC1186 Tension adjustable Sling Back (530mm wide) black nylon Not available with Push bar, Trunk Supports, Following armrests 295 ATC0423 Without Back Cushion (only back plate and sliding mechanism) SEAT DEPTH (* only required for option 1120 "without Seat Cushion") ATC0392 380-430mm (15" - 17") ATC0393 430-480mm (17" - 19") ATC0394 480-530mm (19" - 21") Not available with cane holder with Electrical Seat Riser 400mm UPHOLSTERY COLOUR (for Easy-Adapt seat & back cushion) ATC0269 Black ATC0278 Dartex ATC0289 Grey plush ATC0267 LK Version (Black with orange seam) ARMREST ATC0635 Fixed Armrest, 250-340mm height adj and removable NC if SW is more than 50mm smaller than backrest width ATC0636 Fixed Armrest, 290-380mm height adj and removable NC if SW is more than 50mm smaller than backrest width ATC0620 Following armrest Not available with Tray, Centre and Trunk Supports 488 ARMPADS ATC0647 Standard Armpad (325mm) ATC0649 Armpad extended (+ 50mm) SEAT ACCESSORIES SKIRTGUARD ATC0623 Skirt guard for following armrest 123 HEADREST - Adequate headrest option must be selected ATC1432 Headrest, sideways adjustable 159 ATC1427 Headrest with cheek support, sideways adjustable 181 ATC1495 Equivalent non-invacare Headrest supporting the requirements of ISO7176-19:2001, provided independently from this order TRUNK SUPPORT ATC1356 Lateral trunk support, (Dartex) adjustable (pair) 268 ATC1447 Lateral trunk support, (Dartex) multi adjustable with flexible pads (pair) 239 PUSH BAR ATC1307 Push Bar 77 SEAT ADJUSTMENTS SEAT HEIGHT & SEAT RISER ATC1023 Fixed Seat Height 450mm (17.75") ATC1025 Fixed Seat Height 480mm (19") ATC1030 Electrical Seat Riser (400mm - 650mm) (16" - 25.5") 962 ATC1040 Electrical Seat Riser (440mm - 690mm) incl. adapter (17.25" - 27") 1,022 SEAT TILT ATC1002 Manual Seat Tilt by spindle ATC1014 Electrical Tilt 0 to 25 477 BACKREST RECLINER ATC0951 Manual Recliner, hand wheel RH (with shearing compensation) ATC0952 Manual Recliner, hand wheel LH (with shearing compensation) ATC0947 Electrical Recliner (with shearing compensation) 421 LEGREST LEGREST FIXATION POSITION ATC0590 X Position for seat cushion up to 70mm thick Page 2 of 5
FOOTREST HANGER TYPE ATC0503 Hanger Vari F pair (Adj with tools) ATC0533 Hanger Vari A pair (Adj with Hand Knob) Not available with Fixed footplate or footboard 58 ATC0532 Hanger ADM 0-80 pair (Manual Elevators) Not available with Fixed footplate or footboard 181 ATC0531 Hanger ADE 0-80 pair (Electric Elevators) Not available with Fixed footplate or footboard 517 FOOTPLATE TYPE ATC0512 Fixed Footplate pair ATC0504 Angle Adjustable Footplate pair 58 ATC0513 Angle and depth adjustable Footplate pair (Adapt) 94 ATC0522 Angle Adjustable Footboard Not available with Kerbrider 121 CENTRE MOUNTED LEGRESTS FOOTREST HANGER TYPE ATC0557 Hanger, centre mounted, length compensating, electric. driven Not available with Kerbrider 477 ATC0556 Hanger, centre mounted, angle settable Not available with Kerbrider LOWER LEG LENGTH ATC0524 Short 320-380mm ATC0534 Medium 380-440mm CALF PADS ATC0583 Calf pads FOOTPLATE ATC0559 Angle Adjustable Footplate REMOTE DX2 SYSTEM REMOTE & BRACKET ATC1638 REM A, w/o light function (up to 4 actuators) Not available with Electric Riser, LED Lights or 10km/h motor ATC1639 REM B, including light function (up to 4 actuators) Not available with Electric Riser 125 ATC1601 ACS REM 24SD 165 ATC1614 G90A 190 Head-Remote, ultrasonic proximity sensor(only available as special Contact UK Specials Dept POA ATC1207 Standard Bracket RH ATC1208 Standard Bracket LH ATC1707 Swing Away + height adjust. RH high end 105 ATC1708 Swing Away + height adjust. LH high end 105 ATTENDANT REMOTE + BRACKET ATC1643 REM Type A (up to 4 electric actuators) Not available with LED Lights or 10 km/h motor 15 ATC1644 REM Type B (up to 4 electric actuators and light functionality) 145 ATC1602 ACS REM 24SD 171 ATC1616 G90A 171 ATC1207 Standard Bracket RH ATC1208 Standard Bracket LH TRAY CONTROL + BRACKET ATC1607 Tray Remote REM 41 Not available with Bumper Remote 289 ATC1289 Swing Away RH ATC1288 Swing Away LH CENTRE CONTROL + BRACKET ATC1608 Centre Remote REM 24SD Not available with Bumper Remote 181 ATC1289 Swing Away RH ATC1288 Swing Away LH DUAL CONTROL (can only be selected as an addition to user remote) ATC1720 Compact Dual Control 445 ATC1207 Standard Bracket RH ATC1208 Standard Bracket LH Page 3 of 5
INVACARE IDC DUAL CONTROL + BRACKET ATC1645 Invacare IDC Dual control 585 ATC1221 Detachable Bracket RH ATC1222 Detachable Bracket LH DRIVE UNIT OPTIONS SHROUD COLOUR ATC0202 Blue ATC0228 Black ATC0220 Champagne ATC0204 Transparent Cherry Red ATC0222 White ATC0216 Olive green ATZ0299 Special Shroud Colour (RAL code required) POA FRONT WHEEL ATC0851 3.00-6 Grey Pneumatic ATC0853 3.00-6 Grey Puncture Proof (sealed) ATC0855 3.00-6 Grey Puncture Proof (solid inlay) 85 REAR WHEEL ATC0771 3.00-8 Grey Pneumatic ATC0773 3.00-8 Grey Puncture Proof (sealed) ATC0750 3.00-8 Grey Puncture Proof (solid inlay) 85 PERFORMANCE OPTIONS MOTORTYPE ATC1277 6 km/h (4mph) ATC1285 10 km/h (6mph) (Price includes Lights) lights must also be chosen 482 BATTERY ATC1364 X 70 Ah Gel REAR SUSPENSION ATC1240 Suspension low (up to 80kg user weight) ATC1241 Suspension middle (from 70kg up to 100kg user weight) ATC1242 Suspension hard (from 90kg up to 150kg user weight) PERFORMANCE ACCESSORIES G-TRAC ATC1215 G-Trac Module 653 CHARGER ATC1343 X Charger 8A (200-250V) SAFETY OPTIONS LIGHT ATC1437 LED Light system with indicators 360 ATC1254 Without Light system ANTI-TIPPER ATC1205 Anti-tipper (standard version) SAFETY ACCESSORIES KERB RIDER ATC1244 Kerb Rider 168 TRANSPORTATION KIT ATZ1450 Preparation for DAHL-Docking station, (Adequate headrest is compulsory) Not available with Kerbrider 324 ATC1494 X 4-Point tie-down (Tested version for using wheelchair as a vehicle seat according to ISO 7176-19:2001) (Adequate headrest is compulsory) FIXATION BELT ATC1329 Lap Belt with Auto Lock ATC1332 H-Belt 60 REARVIEW MIRROR ATC1415 RH ATC1339 LH Page 4 of 5
ACCESSORIES LUGGAGE RACK ATC1394 Luggage Rack 261 CANEHOLDER ATC1312 RH Not Available with RH Manual Recliner 33 ATC1363 LH Not Available with LH Manual Recliner 33 TRAY - mounted opposite side to controller ATC1404 Swing Away RH 278 ATC1405 Swing Away LH 278 FENDER ATC1416 Fender for front Wheels 96 ATC1417 Fender for rear Wheels 96 TOOLKIT ATC1333 X Toolkit (included 2x Screwdriver, 3x allan key, open-jawed spanner and main fuse) BUMPER ATC1366 Bumper for Remote Not available with user G90A or Attendant REM 24SD 31 TOTAL PRICE Please refer to 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