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

Similar documents
R82 Caribou - E0641. 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

R82 Stingray - E1233

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

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

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

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

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

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

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

Canadian Suggested Retail Price List April 2015

R82 Flamingo Flamingo High-Low

Standard Base Price: 618

Phone: Nov-17

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

RETAIL Max user weight: 100kg - seat widths 12" & 13" Max user weight: 130kg -seat widths 14" -16"

Standard Base Price: 539

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

Page 1/133. Price and ordering list. Mustang B (Shoulder height)

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

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

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

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

Invacare Action 3 Junior Basic RETAIL Max User Weight 80Kg (12.5 stone)

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

SHIPPING INFORMATION. Order

Basic price 2.250,- Excl. VAT

Stallion Script Form Fixed Frame Adjustable Wheelchair 90100

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.

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.

Condor Script Form Folding Frame Day Wheelchair 90050

FUSION Seating Prescription Form Custom Built Seating System

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

Positioning Components Order Form - ODJFS Only

motivation Product Summary

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

MASS Script Form. Frame. Backrest. Seat Depth. Tsunami ALX K0005 Charge. Sling Position. Seat Width / Seat Depth. Seat Width.

Condor Script Form Folding Frame Day Wheelchair 90050

MASS Script Form. Frame. Backrest. Seat Depth

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.

NXT Pediatric. Manual Wheelchair. Transport Optional Base

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.

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

champion Standard Base Price 1,875 Standard Features

USA Parts List FUZE T20

USA Parts List FUZE T50

BINGO Evolution rehab pushchair

BATTERY BOX BATTERY BOX. Pos Item number Description CommentDescription BATTERY COVER QTY

Please choose the seat width for accessories: 35 cm 40 cm 43 cm 45 cm 50 cm

Order Date : k-series. titanium. Please make your selection with a cross in the box Standard feature Free of Charge

SHIPPING INFORMATION Provider Acct #:

Leckey Squiggles Seat

Order no.: ... Date Signature. Posterior seat height

Please make your selection with a cross in the box Standard feature Free of Charge

Manual Wheelchair Pencoed Technology Park. DEALER Prescription form Pencoed. CF35 5AQ. LPF1U2ULTRALIGHT211113D Tel: Fax:

champion carbon Customer weight = Kg Code X Description Dealer SEATING CHOICE DDF0204 küschall Champion Carbon 85 Frame Angle

SEATING CHOICE TITANIUM FRONT FRAME

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

Order form LEVO LAE 2011/1

SHIPPING INFORMATION Provider Acct #:

Canada Quote / Order Form Combi

Prime Engineering Superstand

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

Spare parts & accessories

NEMO VERTICAL Authorised client weight 100 kg + 10 kg additional load ISO-CRASH TESTED

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

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

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.

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

Mygo Seat Spare Parts Catalogue

Küschall K Series DEALER Maximum user weight 120kg ( 19 Stone )

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

Küschall Champion DEALER Maximum user weight 120kg (19 Stone)

Chair Back Solid. Chair Back. Chair Back. Chair Back

Küschall K - Junior INVACARE IRELAND LTD Maximum user weight 60kg ( 9.5 Stone )

Prime Engineering GRANSTAND II

Paediatric Products. Testimonials

Black -01 Moss green -95 Yellow -99. Heather purple -97. Indicate height. Indicate height. Indicate angle. Indicate height: cm. Indicate height: cm

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

Quickie IRIS January 2014

Table of Contents. Order By: Trays. Positioning Straps. Seats and Backs. Bracket Hardware. Electronics. Seating Accessories. Order Forms.

For the Modulite Teen seating please select the underlined options on this form and include a completed Modulite Teen Seating form

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

MEDmobility Calgary Trail NW Edmonton AB T6H 2K1 P: F:

Küschall Champion DEALER Maximum user weight 120kg (19 Stone)

Küschall Ultra Light RETAIL Maximum user weight 130kg (20.5 Stone)

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

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

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

k-series Aluminium Standard Features

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

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

Transformer. Rev C. Aug 15, 2010 Page 1 of 8

USA Parts List BENTLEY

Etac Cross 5 and Cross 5 XL

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

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

Transcription:

R82 Rabbit Up - E0638 / E0642 USD 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 Effective: 02.01.19 - Rev 3 Rabbit Footplate/Extra Foot Adj. Knee Support Hip/Side Support Back Support Chest Support Tray Head Support A (Total Height) B (Shoulder Height) C (Chest Height) D (Buttock Height) E (Chest Width) F (Shoulder Width) Age Weight Features, incl. in standard price Stander Frame Centre Bar Brake on Castors Angling Spindle Measurements Mobile Stander Frame Centre Bar Driving Wheels Angling Spindle Closed Pushrim Std. Camber Angle Spoke protectors Central brake Size 1 Size 2 Size 3 Size 4 Measurements as a stander inches inches inches inches Overall width (G) 20¼" 21¾" 23¾" 23¾" Length (H) 27¾" 31¼" 31¼" 36½" Total mass 19.8 lbs. 23.1 lbs. 24.2 lbs. 29.3 lbs. Measurements as a mobile stander w/26" wheels w/32" wheels w/32" wheels w/36" wheels Overall width (G) 25" 26¾" 28¾" 28¼" Length (H) 24½" 29½" 29½" 35½" Total mass 29.75 lbs. 34.1 lbs. 35.25 lbs. 40.75 lbs. Overall measurements Width, inside (G1) 12¾" 14¾" 16¾" 16¾" Overall height (I) * 26 ¼" 39 ¼" 33 ¾" 46 ¾" 39" 51 ½" 47 ¼" 60 ¼" 26½" - 39¼" 33½" - 46½" 39" - 51½" 47¼" - 60¼" Height from foot plate (I1) * 21 ¾" 29 ¼" 29 ½ " 42 ½" 32 ½" 46 ¾" 37 ¾" 56" 21¾ - 29¼" 29½" - 42½" 32¾" - 46¾" 37¾" - 56" Center bar angle (a1) 0 to +30º 0 to +30º 0 to +30º 0 to +30º Foot plate angle (a2) +15º to -10º +15º to -10º +15º to -10º +15º to -10º Standard Camber 8º 6º 6º 4º Center bar length 19¾" 27½" 31½" 39¼" Max load 88.1 lbs. 110.2 lbs. 132.2 lbs. 154.3 lbs. * Measured in upright position and with the foot plate in the lowest position.

Description Size Part No. USD Price HCPCS Stander - with brake on castors Rabbit-up, Stander, Yellow 1 8621220-00 $1,372 E0638 Rabbit-up, Stander, Blue 2 8622220-00 $1,407 E0638 Rabbit-up, Stander, Grey 3 8623220-00 $1,442 E0638 Rabbit-up, Stander, Silver 4 8624220-00 $1,547 E0638 Description Size Part No. USD Price HCPCS Rabbit, 22" Wheels, Yellow 1 8621222-21 $2,632 E0642 Rabbit, 24" Wheels, Yellow 1 8621223-21 $2,632 E0642 Rabbit, 26" Wheels, Yellow 1 8621224-21 $2,632 E0642 Rabbit, 26" Wheels, Blue 2 8622224-21 $2,667 E0642 Rabbit, 29" Wheels, Blue 2 8622225-21 $3,297 E0642 Rabbit, 32" Wheels, Blue 2 8622226-21 $3,297 E0642 Rabbit, 26" Wheels, Grey 3 8623224-21 $2,702 E0642 Rabbit, 29" Wheels, Grey 3 8623225-21 $3,332 E0642 Rabbit, 32" Wheels, Grey 3 8623226-21 $3,332 E0642 Rabbit, 32" Wheels, Silver 4 8624226-21 $3,437 E0642 Rabbit, 36" Wheels, Silver 4 8624227-21 $3,542 E0642 (Includes central brake, spindle, spoke protectors, & standard camber). Non-returnable item 2 of 5

Chest Support 11" x 15½" x 7½ 1 861704 $205 Chest Support 11" x 20-27" x 7½ 2, 3 861702 $205 Chest Support 16" x 25-32" x 10½ 4 861703 $225 Height and width adjustable Chest Support (Pony Style) 5½" x 8¾" x 4¾ 1 861801 $295 Chest Support (Pony Style) 5½" x 10¾" x 4¾ 2, 3 861802 $295 Chest Support (Pony Style) 5½" x 12¾" x 4¾ 4 861803 $295 Thicker Pad, Custom Order; Approx. lead time: 6-8 weeks Chest Support (Mustang Style) 15½"-25¼" Small 861810 $490 Chest Support (Mustang Style) 26¼"-30¾" Medium 861820 $510 Chest Support (Mustang Style) 34¼"-44¾" Large 861830 $540 Surrounding Pad Style Extra Pad H:4¾ x W:2¼ One Size 869225 $61 For Mustang Style Chest Support Cover for Chest Support Small 869810-160 $115 Cover for Chest Support Medium 869820-260 $140 Cover for Chest Support Large 869830-360 $150 Filler Pad 4¼ Small 861421 $82 Adds 1" expansion to chest or hip pads Filler Pad 6¼ Large 861422 $82 Adds 2" expansion to chest or hip pads Extension for Center Bar 3" One Size 861480 $82 Note: Allows chest support to be mounted in a higher position Tray with Storage Box One Size 862501 $395 Height Adjustment of Tray One Size 862510 $225 Can only be used with Chest Support Tray, Plastic, Grey One Size 862515 $385 Abdominal Support (Ea.) 5" x 7½" One Size 861411 $160 Pommel and Sacral Support (Ea.) 5" x 7½" One Size 861401 $435 NOTE The following items are required when ordering a Head Support: Connecting System for Head Support Headrest of Choice Turtle Bar System Hip Support w/ Pommel Connecting System for Head Support 1, 2 861424-3 $258 Connecting System for Head Support 3, 4 861424-4 $258 Required with Head Support Anatomic Head Support A:5½ x B:5½ x C:9½ Small 5099001 $255 Head Support Cover (Required) Small 9923-83 N/C Anatomic Head Support A:6 x B:5½ x C:10 Medium 5099002 $255 Head Support Cover (Required) Medium 9945-83 N/C Anatomic Head Support A:6½ x B:5½ x C:12½ Large 5099003 $255 Head Support Cover (Required) Large 9967-83 N/C Required: Turtle Bar System Short or Long, Connecting System for Head Support AND Hip Support. 3 of 5

Swing-away Mounting Brackets - Height, Depth, Angle and Lateral Adjustable Turtle Bar System A: 5, B: 4-8½ Short 98619-25 $230 Turtle Bar System A: 10, B: 4-8½ Long 98619-26 $230 Required with Anatomic Head Support; 5099001, 5099002 or 5099003 Other types of headrest available, please see Head Supports Order Form Hip Support w/ Pommel 4¼" x 6" x 3 1 861501 $505 Hip Support w/ Pommel 4¼" x 8-10½" x 3 2, 3 861502 $505 Hip Support w/ Pommel 6¼ x 10-11½" x 4 4 861503 $560 Height and Width Adjustable, Required w/ Head Support Hip Support, Front Mount 4¼" x 6" x 3 1 861601 $235 Hip Support, Front Mount 4¼" x 8-10½" x 3 2, 3 861602 $235 Hip Support, Front Mount 6¼" 10-11½" x 4 4 861603 $265 Height Adjustable Height and Width Adjustable Hip Support w/rotation 4¼" x 6" x 3 1 861611 $355 Hip Support w/rotation 4¼" x 8-10½" x 3 2, 3 861612 $355 Hip Support w/rotation 6¼" x 10-11½" x 4 4 861613 $385 Height Adjustable Height and Width Adjustable Height and Width Adjustable, Custom Order; Approx. lead time: 6-8 weeks. Hip Support, Surrounding 1 861610 $555 Hip Support, Surrounding 2, 3 861620 $555 Hip Support, Surrounding 4 861630 $565 Knee Supports (Pr.) 2½" x 2½" 1 861301 $280 Knee Supports (Pr.) 2¾" x 3¼" 2, 3 861302 $355 Knee Supports (Pr.) 2¾" x 4" 4 861303 $355 Hinged Knee Supports (Pr.) 3" 1 861311 $435 Hinged Knee Supports (Pr.) 3¾" 2, 3 861312 $435 Hinged Knee Supports (Pr.) 4½" 4 861313 $435 Flip-up Footplate 12" x 12" 1 861211 $220 Flip-up Footplate 17" x 14" 2, 3, 4 861212 $220 Required with all Footplate Accessories Formed Footplates (Pr.) 6¾" 0 86149 $165 Formed Footplates (Pr.) 4" x 8½" 1, 2 86147 $165 Formed Footplates (Pr.) 4½" x 9½" 3 86148 $165 Flip-Up Footplate Required; 861211 or 861212 Foot Straps, Plastic Lock (Pr.) Max: 22", A: 13½-20½ One Size 85096 $36 Foot Straps, Velcro (Pr.) One Size 85102 $51 Hinged Sandals w/straps (Pr.) 3¾" x 8" 1 861221 $135 Hinged Sandals w/straps (Pr.) 4½" x 9½" 2, 3 861222 $135 Hinged Sandals w/straps (Pr.) 6" x 12" 4 861223 $135 Flip-Up Footplate Required; 861211 or 861212. Individual Footrest w/hinged Sandals (Pr.) 1 861201 $395 Individual Footrest w/hinged Sandals (Pr.) 2, 3 861202 $395 Heel Stop (Pr.) 1½" x 4" Small 861251 $56 Heel Stop (Pr.) 4" x 5¾" Large 861252 $56 Flip-Up Footplate Required; 861211 or 861212 4 of 5

Conversion Kits For stander not prepared for driving wheels order driving wheels and central brake system* Driving wheels, 22" closed pushrim 1 134209 $473 Driving wheels, 24"closed pushrim 1 134210 $473 Driving wheels, 26" closed pushrim 1, 2, 3 134211 $473 Driving wheels, 29" closed pushrim 2, 3 134212 $998 Driving wheels, 32" closed pushrim 2, 3, 4 134213 $998 Driving wheels, 36" closed pushrim 4 134214 $1,103 * with spoke protector Central brake system 1 134215 $263 Central brake system 2, 3 134216 $263 Central brake system 4 134218 $263 *for stander not prepared for driving wheels Camber kit Rabbit Up 0 134200 $35 Camber kit Rabbit Up +3/-3 134201 $35 Camber kit Rabbit Up +6/-6 134202 $35 Spare Parts QTY Strap for Hip & Chest Support 1 861621 $61 Strap for Hip & Chest Support 2, 3 861622 $61 Strap for Hip & Chest Support 4 861623 $61. Kit for Center Bar 2 862902 $160 Kit for Center Bar 3 862903 $180 Kit for Center Bar 4 862904 $190 Custom order; Approx. lead time: 6-8 weeks Spare Parts QTY Mounting for Back Support 1, 2, 3, 4 861451 $133 Straps for Knee Supports (Pr.) 1 861341 $56 Straps for Knee Supports (Pr.) 2, 3 861342 $56 Straps for Flip-Up Footplate (Pr.) 1 861241 $87 Straps for Flip-Up Footplate (Pr.) 2, 3, 4 861242 $87 Spoke Protector for wheels w/closed push rim (Ea.) 22" 862622 $135 Spoke Protector for wheels w/closed push rim (Ea.) 24" 862624 $135 Spoke Protector for wheels w/closed push rim (Ea.) 26" 862626 $135 Spoke Protector for wheels w/closed push rim (Ea.) 29" 862629 $190 Spoke Protector for wheels w/closed push rim (Ea.) 32" 862632 $190 Spoke Protector for wheels w/closed push rim (Ea.) 36" 862636 $190 **Open Pushrim available upon request Custom order; Approx. lead time: 6-8 weeks HCPCS codes are provided for your convenience and are NOT to be considered billing or legal advice. Providers are responsible for insuring that all appropriate billing codes are used when submitting claims. Proper use of HCPCS codes does not insure coverage or payment. Contact the appropriate payer for coverage information. For shipping rates, please call 1-844-876-6245 12801 E Independence Blvd, Matthews, NC 28105 1-844-876-6245 Web: www.r82.com Prices in CAD & is subject to change without notice For Quotes and Orders please send completed Order Form to: us.info@r82.com 5 of 5