discovery tmax Base price: EUR x,xxx q Provide estimate only q Order q Order no.: Attachment for custom fabrication enclosed

Similar documents
discovery tmax Base price: EUR x,xxx q Provide estimate only q Order q Order no.: Attachment for custom fabrication enclosed

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

Start M2S. Lightweight wheelchair. Unit price: EUR X,XXX (side panels and footrests included) Provide estimate only Order. Standard equipment

Kimba Neo. Paediatric postural positioning system. Base price Outdoor mobility base: EUR x,xxx. Base price Seating unit: EUR x,xxx

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.

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.

Height adjustable footplates, equipped with nylon heel loops. Standard with maintenance free PU front (7 ) and rear wheels (24 ).

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

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

Quickie IRIS January 2014

Auftrags-Nr.: Order no.: ... Date Signature. MA 110 Standard

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

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

Standard Base Price: 539

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

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.

Quickie QX July 2017

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.

Leckey Squiggles Seat

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

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

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

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.

Quickie QX December 2018

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.

q Little Wave Flip XP-Rigid Base E1233, E1161 $

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

Quickie QXi AADL. EIF6, October ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To City: Fax. Price 1. FRAME $2,

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

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

Quickie IRIS March 2015

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

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

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

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

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

USA Parts List BENTLEY

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

Sling Position. Push Handle. q Omit Push Handles N/C q Standard Push Handles 53 q Fold Down Push Handles 80 q Bolt-On Push Handles 109

Condor Script Form Folding Frame Day Wheelchair 90050

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.

Parts Catalog Issued: Mar 12, Comet Rocket. Wheelchairs

Invacare Kite (Max Seating System) Retail Max User Weight 160Kg (25 stone)

ZIPPIE IRIS (Transit Included) EIZ5A

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

Invacare Kite (Max Seating System) Retail Max User Weight 160Kg (25 stone)

2004 Medicare Billing Guidelines for Rehab Products

SIDEFRAME (FIXED ARM), CROSSBRACE, ARM PAD KIT...3 SIDEFRAME (DETACHABLE ARM), CROSSBRACE...4 ARM, DETACHABLE...5 CASTER...5 REAR WHEEL...

SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5

NXT Pediatric. Manual Wheelchair. Transport Optional Base

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

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

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

MASS Script Form. Frame. Backrest. Seat Depth

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

SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5

USA Parts List FUZE T20

Stallion Script Form Fixed Frame Adjustable Wheelchair 90100

USA Parts List FUZE T50

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

Invacare Storm4 Easy Adapt Retail Max User Weight 150kgs (23.5 stone) Standard Features

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

QUICKIE S646 SE BD/SD/MPD No Power, Single Power & Multi Power Seating Option AADL - W579

ORDER FORM Ver.9.0 Rev DEALER COLOURS INFORMATION For Office Use Only Dealer: Order Date: S/N: Account: P.O.#: RTS Ordered By: RTS: Phone:

SHIPPING INFORMATION Provider Acct #:

Quickie GTX Swing-Away FSS NET ORDER FORM/PRICE LIST (SIN F-1)

Condor Script Form Folding Frame Day Wheelchair 90050

Shower commode chairs

MALTE Posterior Walking Aid

SHIPPING INFORMATION Provider Acct #:

Parts Catalog Issued: Aug 1, Patriot. Wheelchair

4.1 MOVE. ORDER FORM - CANADA Ship to: Name: Address: Account: Vendor: Date: Ordered by: Marked for: User manual: PO: Postal Code: Phone:

SIDEFRAME AND CROSSBRACE... 3 ARM: FLIP-BACK FIXED-HEIGHT... 4 ARM: FLIP-BACK ADJUSTABLE-HEIGHT... 4 REAR WHEEL... 5 CASTER... 5

NAME PHONE NO ACCOUNT# P.O. DATE ADDRESS

CareGuard by Invacare

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

Invacare. Family Compatibility Portfolio Optimize your business with an all-in-one solution. Jan

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

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

Wheelchair, foldable heavy duty

PAGE 2 BREEZY ELEGANCE

Bora. Standard Base Price 4,100. Standard Features SEAT DEPTHS

Shower commode chairs. Ocean. Series

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

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

Quickie GTX Fixed Frame EIF3, Effective July 2009

WHEELCHAIR SPECIFICATION GUIDE

MVP / MVP jr. (After 10/15/01) Xtra (After 8/31/04)

4.6. Clinician/ATP/RTS: City: State: C2MA029 * Required

Aquatec Ocean Family. Ocean Family. Aquatec

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

QUICKIE P222 SE BD/SD Solid Seat (No Power or Single Power Seating Options) EIPW2 - Effective January 2018

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

adult Kanga TS wheelchair

October 2018 EIQ2X. Mark For: Submitting for: Quote Order. ADDITIONAL SHIPPING INFORMATION Dealer Contact: Price. Option # 1. FRAME 002RS1 002RS2

Invacare FOX (Modulite Seating System) Retail Max User Weight 127Kg (20 stone)

Quickie 2 January 2014

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

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

Transcription:

BITTE DETACH HIER HERE ABTRENNEN AND SEND UND BY ZU FAX OTTO TO OTTO BOCK BOCK FAXEN Base price: EUR x,xxx All prices in EUR, valid from 01/01/2012 to 31/12/2012 Order no.: discovery tmax Article number: 470G22=00000_K q Provide estimate only q Order q Attachment for custom fabrication enclosed Billing address/customer number Technische Änderungen und Druckfehler vorbehalten Technical modifications and printing errors reserved. Delivery address Sales person Name... Date Signature Standard equipment -5 tilt +50 tilt in space cable free foot release rear wheels 12", 16", 22" or 24" solid caster wheels 6", 7" or 8 single push canes push to lock, wheel lock" Ottobock 647F400=EN 12.03 adjustable push bar transport brackets side plates discovery tmax 1/6

tmax Kids [ ] tmax Kids Seat width (between armrests) 30 40 cm / 12" 16" (seat width at outside seat rails -2,5 cm/1") Seat depth from back canes to front of the seat rails 30 40 cm / 12" 16" (without back canes +2,5 cm/1") Basic Price Please choose the pre setup: tmax Kids 300 mm (12") Seat depth 325 mm (13") 350 mm (14") 375 mm (15") 400 mm (16") Seat width (between armrests) / seat width at outside seat rails -2,5 cm/1" 300 mm (12") 325 mm (13") 350 mm (14") 375 mm (15") 400 mm (16") tmax Adult [ ] tmax Adult Seat width (between armrests) (seat width at outside seat rails -2,5 cm/1") [ ] 35 45 cm / 14" 18" [ ] 40 50 cm / 16" 20" [ ] 45 56 cm / 18" 22" Seat depth from back canes to front of the seat rails (without back canes +2,5 cm/1") [ ] 30 40 cm / 12" 16" [ ] 37 47 cm / 15" 19" [ ] 45 56 cm / 18" 22" Please choose the pre setup: Seat depth Seat type tmax Adult Seat Pan sizes 300 mm (12") 325 mm (13") 350 mm (14") 350 mm (14") Seat width (between armrests) / seat width at outside seat rails -2,5 cm/1" 375 mm (15") 400 mm (16") 425 mm (17") 450 mm (18") 475 mm (19") 500 mm (20") 525 mm (21") 375 mm (15") 400 mm (16") 425 mm (17") 450 mm (18") 475 mm (19") 500 mm (20") 525 mm (21") 550 mm (22") SA 10 [ ] Without Seat Pan 550 mm (22") SA 11 [ ] Seat Pan with adjustable drop hooks and countersink holes add. charge Seat depth Seat width (between armrests) 300 mm 400 mm (12" 16") 350 mm 450 mm (14" 18") 400 mm 500 mm (16" 20") 450 mm 550 mm (18" 22") 300 mm 400 mm (12" 16") 471C22=SS026 471C22=SS027 375 mm 475 mm (15" 19") 471C22=SS028 471C22=SS029 471C22=SS036 471C22=SS037 450 mm 550 mm (18" 22") 471C22=SS038 471C22=SS039 discovery tmax 2/6

Back type SD 01 [ ] Single push handles short Height (from seat to bend handle) 530 mm / 21,2" SD 02 [ ] Single push handles long Height (from seat to bend handle) 630 mm / 24,2" SD 03 [ ] Angle adjustable push bar, short, Height (from seat to bend handle) 530 mm / 21,2" SD 04 [ ] Angle adjustable push bar long, Height (from seat to bend handle) 630 mm / 24,2" SD 05 [ ] Single push handles, height adjustable 53 63 cm / 21,2" 24,2" SD 06 [ ] Push bar, height and angle andjustable 53 63 cm / 21,2" 24,2" Seat to back angle (please choose pre setup) [ ] 85 [ ] 90 [ ] 95 [ ] 100 [ ] 105 [ ] 110 [ ] 115 [ ] 120 Front rigging SB 01 [ ] Without front rigging SB 02 [ ] 75, swing in/out Footrests SB 10 [ ] Single footplates (composite) SB 11 [ ] Single footplates (aluminum) SB 14 [ ] Single footplates for lower leg length (only tmax kids) Footrest options SB 20 [ ] Leg strap SB 21 [ ] Heel loop pair Frame options SA 01 [ ] Rear anti-tip right SA 02 [ ] Rear anti-tip left SA 03 [ ] Tip assist right SA 04 [ ] Tip assist left Armrest SE 01 [ ] Without armrest SE 02 [ ] Armrest fixed height SE 03 [ ] Armrest height adjustable Armpad SE 20 [ ] Armpad short (pair) SE 21 [ ] Armpad long (pair) SE 22 [ ] Without armpad Side guard SE 10 [ ] Without side guard SE 11 [ ] Side guard for armrest (pair) Transit Option SK 01 [ ] Without transit option SK 02 [ ] 4 transport brackets and wheelchair anchor for pelvic belt (tested according ISO 7176-19, max. load 100kg/220lbs) discovery tmax 3/6

Frame colours 010 [ ] Dormant marine blue 011 [ ] Sparkle granny smith/metallic green 013 [ ] Deep black 014 [ ] Candy red 016 [ ] Silver metallic 019 [ ] White pearl (only for tmax adult) 021 [ ] Purple (only for tmax kids) 022 [ ] Pink (only for tmax kids) Front casters SF 01 [ ] 6" pneumatic SF 02 [ ] 6" solid PU SF 03 [ ] 7" pneumatic SF 04 [ ] 7" solid PU SF 05 [ ] 8" pneumatic SF 06 [ ] 8" solid PU Rear wheel options SG 01 [ ] 12 1/2" composite wheel SG 02 [ ] 16" composite wheel SG 03 [ ] 22" quick release SG 04 [ ] 24" quick release Rear Tire options SG 10 [ ] Pneumatic SG 11 [ ] Solid PU Wheel lock options SH 01 [ ] Push to lock wheel locks (pair) SH 05 [ ] Wheel lock extension SH 07 [ ] Attendant Hublock cane mount (not for 16") discovery tmax 4/6

Seat height, please choose pre setup: Seat height tmax Kids 12 1/2" 16" Rear wheel size 22" 24" Seat height, please choose pre setup: Seat height tmax adult 12 1/2" 16" Rear wheel size 22" 24" Front caster size 6" 7" 8" [ ] 325 mm (13") [ ] 325 mm (13") [ ] 325 (13") [ ] 475 mm (19") [ ] 500 mm (20") Front caster size [ ] 390 mm (15,5") [ ] 420 mm (16,5") [ ] 445 mm (17,5") [ ] 470 mm (18,5") [ ] 495 mm (19,5") [ ] 475 mm (19") [ ] 500 mm (20") [ ] 475 mm (19") [ ] 500 mm (20") 6" 7" 8" [ ] 420 (16,5") [ ] 445 (17,5") [ ] 470 (18,5") [ ] 495 (19,5") discovery tmax 5/6

Technical data Technical data Size 1 (tmax Kids) Size 2 (tmax Adult) Size 3 (tmax Adult) Size 4 (tmax Adult) Frame width (FW) with 12" wheels SW +6" (15 cm) SW +6" (15 cm) SW +6" (15 cm) SW +6" (15 cm) Seat width between armrest (SW) 12-16" (30-40 cm) 14-18" (35-45 cm) 16-20" (40-50 cm) 18-22" (45-55 cm) Seat width at outside seat rails 11-15" (~28-38 cm) 13-17" (~33-43 cm) 15-19" (~38-48 cm) 17-21" (~43-53 cm) Seat depth (SD) 12-16" (30-40 cm) 12-19" (37,5-47,5 cm) 15-22" (37,5-55 cm) 15-22" (37,5-55 cm) Rear wheels 12"/16"/22"/24" 12"/16"/22"/24" 12"/16"/22"/24" 12"/16"/22"/24" Seat height (SH) 13-18" (35-45 cm) 14-20" (ca. 40-50 cm) 14-20" (ca. 40-50 cm) 14-20" (ca. 40-50 cm) Tilt in space -5 +50-5 +50-5 +50-5 +50 Height back canes from seat plate Back rest inclination 85 120 85 120 85 120 85 120 Frame length with 12 1/2" wheels (without footrest and anti tipper) from ca. 21" from ~53 cm from ca. 24" from ~61 cm from ca. 24" from ~61 cm from ca. 27" from ~68,5 cm Max. load incl. seat unit 90 kg/200 lbs 136 kg/300 lbs 136 kg/300 lbs 136 kg/300 lbs Frame weight (without seat, footrest, armrest, rear wheels) 15 kg/33 lbs 16 kg/35 lbs 16,5 kg/36 lbs 17 kg/37,5 lbs Front casters 6"/7"/8" 6"/7"/8" 6"/7"/8" 6"/7"/8" discovery tmax 6/6