SHIPPING INFORMATION. Order

Similar documents
SHIPPING INFORMATION Provider Acct #:

SHIPPING INFORMATION Provider Acct #:

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

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

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

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

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

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

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

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

Positioning Components Order Form - ODJFS Only

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

Quickie IRIS January 2014

JAY Fit. Backrest and Seat Assembly. July 2017

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

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

R82 Stingray - E1233

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

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

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

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.

Phone: Nov-17

USA Parts List FUZE T50

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

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

Basic price 2.250,- Excl. VAT

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

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.

FUSION Seating Prescription Form Custom Built Seating System

USA Parts List FUZE T20

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

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

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.

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

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

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

Quantum 600 Series Group 3 Single Power & Multiple Power Order Form/ODJFS Only 300 lbs. weight capacity. Revised: December 13, 2012 Page 1 of 7

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

Quantum Rehab A Division of Pride Mobility Products Corporation

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

Traxx 3 & Atigra 2 Script Form

USA Parts List BENTLEY

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

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

JAY AES - QUICK ORDER FORM November 2012

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

JAY AES - PACKAGE ORDER FORM November 2012

2016 EZ RIDER UPRIGHT PRODUCT PPT

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

KID-KART TLC... 3 BASE... 3 BASE - Discontinued... 3 SILVER BASE... 4 CASTER FORK ASSEMBLIES... 5 WHEEL LOCKS... 6 ANTI-TIPS... 7 REAR WHEELS...

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

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.

Account Number: Provider Name: Contact:

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

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

INDUSTRIES, INC. PRODUCT CATALOG C121

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

CUSTOM INCEPTION CUSHION ORDER FORM HCPC CODE: E2609

Account Number: Provider Name: Contact:

Customer code C- Invoice address. Max. 90 kg See page 5 Side upholstery (reduces SW with 2 x 2 cm) = Standard equipment

Canadian Suggested Retail Price List April 2015

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.

NXT Pediatric. Manual Wheelchair. Transport Optional Base

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.

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

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

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

BREEZY EC WHEELCHAIRS. The best combination of durability, selection and value.

Quantum 1103 Ultra Series Group 2 Single Power Order Form 200 lbs weight capacity

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

Quantum Q1121 Series Group 3 Single Power and Multiple Power Order Form 300 lbs. weight capacity

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

Quickie QX July 2017

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

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

Adjustable Height Raised Toilet Seat Model 101 RTS Pricelist/Order Form December 2014

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

Quickie QX December 2018

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

Complement your Zippie with the JAY Zip Cushion and Back designed just for kids! Pediatric Wheelchair Portfolio

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

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

Vision Ultra-single power

Custom Manual Options & ACCESSORIES AUSTRALIA 2013

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

Frame. Pos Item number Description Comment

BEARINGS BEARINGS

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

Canada Quote / Order Form Combi

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

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

Multi Bari. Key features at a glance: Additional options:

Bio-ST ST & ST-HD. Modifications Removable and/or Additional Foam Shape Contour Covers A A A A & A

Quantum 1103 Ultra Series Group 2 Static Seating Order Form 300 lbs. weight capacity

Product List V Adaptive Engineering Lab 102 E Keefe Ave Milwaukee, WI 53212

Tailored seating solutions for the user requiring a custom CONFIGURED product with the ultimate personal FIT.

Transcription:

Size 3 Order Form MASS 2014 Maximum Weight Capacity 215 lbs. 17Wx20Dx26H Seating Capacity Pride Mobility Products Aust Pty Ltd 20-24 Apollo Drive Hallam VIC 3803 Ph: 03 8770 9600 Fax: 03 9703 2960 Date: Provider Acct #: Provider: Provider Contact: Prov. Address: Provider City: ST: ZIP: Attention: Address: SHIPPING INFORMATION Provider Phone: ( ) Fax: ( ) Ship To City: ST: ZIP: Confirmation Email: Quote Order PO#: Ship To: Address: Ship To Phone: ( ) Fax: ( ) DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. HCPCS codes should not be considered as legal advice. All prices Mark For: MEASUREMENT WORKSHEET Age: Height: ft. in. ROCK Size 3 chair, Tilt-in-Space Includes: Tilt in space, dynamic, mobility base, Silver metallic frame color, standard configuration. Weight: lbs. K3223-00 E1161 ROCK Chair - Size 3 A. Sitting Depth B. Trunk Depth C. Trunk Width D. Hip Width E. Top of Shoulder to Seat Figure 1 - Client Measurements F. Lower Leg Length Transit Option - 3222-5100 Seating System and 3222-5200 Back System Required for WC19 Occupied Status.Transit Option must be factory installed and is not retrofitable. 3223-5000 Transit Option Call for "back canes only" special transit configurations. Reaction Dynamic Seating - Std Requires 3223-5800 Angle Adjustable Leg Rests Upholstery Color KRC302 E2295 REACTION Dynamic Component Upper Body Spring Selections 3223-7210C Soft - Pair N/C 3223-7250C Medium - Pair 3223-7280C Hard - Pair N/C Upholstery Color applies to: back cushions lateral pelvic/thigh supports 306 Black/Sport Mesh 311 Vibrant Red/Black/Sport Mesh N/C 309 Purple/Black/Sport Mesh N/C 310 Teal/Black/Sport Mesh N/C Front Rigging 3223-5800 Required with REACTION Dynamic Seating System. 3223-5800 E0990 Angle Adjustable Leg Rest 3223-5800 Required when ordering KRC302 Active Seating Accessory. Knee angle adj. 18 incr. w/press of button. allows active movement of lower leg. Lower Body Spring Selections 3223-7310C Soft - Pair N/C 3223-7350C Medium - Pair 3223-7380C Hard - Pair N/C Page 1 of 6

Foot Plate Requires Front Rigging Selection 3223-5500 90 Fixed Foot Plate N/C 3223-6100 K0040 Quick Angle Adj. Flip-Up Foot Plate -18 to +45 Dorsal/Plantar Flexion. 8 Positions. ROCK 3 Adjustable Depth Seating System 3223-5100 K0108 14-20" Adj. Depth Seat Pan Kids UP LifeForm Contoured Seat Cushion Selections Seat Cushions Incl: 2 Positioning Wedges, Abductor Wedge; Black Mesh Cover Ischial Insert Selection Required 3229-2230 E2294 14" Width, 14-17" Depth 7000-1005C (14") Open Cell Foam 3229-3210 E2294 17" Width, 14"-17" Depth 3229-3401C (17") 3229-3220 E2294 17" Width, 17"- 20" Depth 7000-1006C (14") 3229-3402C (17") K0108 Soft Memory Foam 7000-1007C (14") 3229-3403C (17") K0108 Medium Memory Foam Kids UP LifeForm Seating System Accessories 7000-1004 Extra Positioning Wedges (4) 3222-7100 Wedge for Seat Cushion 3223-7000 Pressure Relief Layer - Soft (14" x 8" x 1") Memory Foam (17" x 20" x 1/2") 3223-7100 Wedge for Seat Cushion (17" x 9" x 1") Synergy Seat Cushion Options CUSASMB1190 E2607 Synergy Solution Cushion 14"x12" CUSASMB1004 E2607 Synergy Solution Cushion 14"x14" CUSASMB1005 E2607 Synergy Solution Cushion 14"x16" CUSASMB1006 E2607 Synergy Solution Cushion 14"x18" CUSASMB1007 E2607 Synergy Solution Cushion 16"x16" CUSASMB1966 E2607 Synergy Solution Cushion 16"x17" CUSASMB1008 E2607 Synergy Solution Cushion 16"x18" CUSASMB1967 E2607 Synergy Solution Cushion 16"x19" CUSASMB1009 E2607 Synergy Solution Cushion 16"x20" CUSASMB1968 E2607 Synergy Solution Cushion 17"x16" CUSASMB1248 E2607 Synergy Solution Cushion 17"x17" CUSASMB1969 E2607 Synergy Solution Cushion 17"x18" CUSASMB1249 E2607 Synergy Solution Cushion 17"x19" CUSASMB1970 E2607 Synergy Solution Cushion 17"x20" CUSASMB1801 E2603 Synergy Solution 1 Seat Cushion 14"x14" W/Gel Layer CUSASMB1802 E2603 Synergy Solution 1 Seat Cushion 14"x16" W/Gel Layer CUSASMB1803 E2603 Synergy Solution 1 Seat Cushion 14"x18" W/Gel Layer CUSASMB1804 E2603 Synergy Solution 1 Seat Cushion 16"x16" W/Gel Layer CUSASMB1805 E2603 Synergy Solution 1 Seat Cushion 16"x18" W/Gel Layer CUSASMB1806 E2603 Synergy Solution 1 Seat Cushion 16"x20" W/Gel Layer CUSASMB1807 E2603 Synergy Solution 1 Seat Cushion 17"x17" W/Gel Layer CUSASMB1808 E2603 Synergy Solution 1 Seat Cushion 17"x19" W/Gel Layer Pride Mobility Produccts. ROCK3 REV. 11/2013 Page 2 of 6

ROCK 3 Back System Options 3223-5200 E2293 Configurable, Contoured, Adjustable Height Solid I-Back System Kids UP Lifeform Back Cushion Options Select 1 if 3222-5200 is Selected. Back Cushions include contouring wedges and lumbar support 3229-3610C 18"-23" Contoured Back Cushion. (I-Back) 3229-3620C 22"-26"" Contoured Back Cushion. (I-Back) 3223-5440C Basic Fixed Height Armrest 12" Thin Profile - Pair Armrest Options 3223-5450 E0973 Adjustable Height Armrest Thin Profile Pad - Pair 3223-6120 E0950 Upper Extremity Positioning Platform Color - Clear Tray - incl clear tray & h/ware 3223-6110 E0950 Upper Extremity Positioning Platform Color - Gray 3223-6860 Angle/Depth Adj. Support Hardware - Req. for all trays 9900-2009 ROCK 3 Padded Tray Cover Rear Wheel Options 3220-19X0D18C 18" Composite Rear Wheels. 3220-19X0D24C 24 Composite Rear Wheels. Requires 3223-5600 angle adjust system Rear Tire Options 3220-190X Full Polyurethane w/treads Page 3 of 6

Rear Anti-Tips 3223-1700 E0971 Rear Anti-Tips with Wheels (Pair) Hand Rims Axle Plate for 24" Wheels Required 3220-1800-DXXC Chrome Hand Rims N/C 3223-5600 Adj. Position Axle System 3220-1810-DXXC Plastic Coated Hand Rim Casters 3223-5640C 8" x 2" Poly Casters N/C Lateral Pelvic/Thigh Supports 3223-5300L E0956 Left Pelvic/Thigh Support Pkg. 3223-5300R E0956 Right Pelvic/Thigh Support Pkg. Lifeform Anterior Pelvic Positioning Belts Medial 4-point pelvic positioning belt recommended with REACTION seating. Positioning belts not for use as a occupant restraint during transit in a motor vehicle. 3610-1214 E0978 LifeForm 2-point 1" Metal PB Buckle, 3.5" pads 3610-1414 E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 3.5" pads 3610-1415 E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 4.5" pads 3610-1227 E0978 LifeForm 2-point 1.5" Metal PB Buckle, 6.5" pads 3610-1427 E0978 LifeForm Medial 4-point 1.5" Metal PB Buckle, 6.5" pads Lifeform Anterior Trunk Support Anterior Trunk Supports not for use as a occupant restraint during transit in a motor vehicle. LifeForm Zipper Opening Dynamic 3610-2230 E0960 Zipper Opening - S 3610-2240 E0960 Zipper Opening - M 3610-2250 E0960 Zipper Opening - L LifeForm Zipper Opening Structured 3610-2330 E0960 Structured Zipper Opening - S 3610-2340 E0960 Structured Zipper Opening - M 3610-2350 E0960 Structured Zipper Opening - L Lifeform Swing-Away Abductor Hardware and Pads 4-way stretch cover included with Lifeform Abductor pads. 3610-6300 E1028 ROCK 3 S/A Abduct. Hardware 3610-6710 E0957 Small Wedge(2"-3"W x 4"L x 3"D) Page 4 of 6 3610-6720 E0955 Med. Wedge (2"-4.5" x 5"L x 3"D) 3610-6730 E0955 Lg. Wedge (3"-5" x 5"L x 4"D)

Lifeform Headrest and Support Hardware - choose pad size incl h/ware 3610-4208 E0955 8" Curved Oval Pad 3610-4800 E1028 LifeForm Removable Headrest 3610-4210 E0955 10" Curved Oval Pad Mounting Hardware (Required for all Headrest Options) 3610-4214 E0955 14" Curved Oval Pad 9900-1080* Universal Head Rest Mount Plate Only* 3610-4310 E0955 Narrow Adjustable Arc Pad 3610-4320 E0955 Standard Adjustable Arc Pad *Accomodates several other manufacturers headrests. Call for details. Lifeform Ankle and Foot Positioning - choose type & size LifeForm Hard Side Foot Stabilizers - LifeForm Ankle Hugger Foot Stabilizers - N/C 3610-5140L K0108 Left - Medium - 4"W 3610-5240L K0108 Left - Medium - 4"W 3610-5140R K0108 Right - Medium - 4"W 3610-5240R K0108 Right - Medium - 4"W 3610-5150L K0108 Left - Large - 5"W 3610-5250L K0108 Left - Large - 5"W 3610-5150R K0108 Right - Large - 5"W 3610-5250R K0108 Right - Large - 5"W Lifeform Swing Away Lateral Support Hardware - choose brkt style & pad type & size Choose your bracket and CURVED pad size Choose your bracket and PLANAR pad size 3610-3210L E0956 Left 1.5" pediatric bracket lateral thoracic support package, 3610-3110L E0956 Left 1.5" pediatric bracket lateral thoracic support package, Planar Pad 3610-3210R E0956 Right 1.5" pediatric bracket 3610-3110R E0956 Right 1.5" pediatric bracket Planar Pad 3610-3220L E0956 Left 2" bracket lateral thoracic support package, 3610-3120L E0956 Left 2" bracket lateral thoracic support package, Planar Pad 3610-3220R E0956 Right 2" bracket lateral thoracic support package, 3610-3120R E0956 Right 2" bracket lateral thoracic support package, Planar Pad Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose Swing-Away Hardware (required) Choose Swing-Away Hardware (required) Requires 3610-3110, 3120, 3210, 3220. Requires 3610-3110, 3120, 3210, 3220. 3610-3310L E1028 Left 1.5" DoubleSwing 3610-3310R E1028 Right 1.5" DoubleSwing 3610-3320L E1028 Left 2" DoubleSwing 3610-3320R E1028 Right 2" DoubleSwing 3610-3310L E1028 Left 1.5" DoubleSwing 3610-3310R E1028 Right 1.5" DoubleSwing 3610-3320L E1028 Left 2" DoubleSwing 3610-3320R E1028 Right 2" DoubleSwing LifeForm 1.5"Swing-Away Width and Depth Ext.(optional) Options Available only with Swing-Away Hardware. 3610-3411L Depth Ext. + 1", pediatric, Left N/C 3610-3421L Depth Ext. + 1", 2" Brkt., Left N/C 3610-3411R Depth Ext. + 1", pediatric, Right N/C 3610-3421R Depth Ext. + 1", 2" Brkt., Right N/C 3610-3412L Width Ext. + 1", pediatric, Left N/C 3610-3422L Width Ext. + 1", 2" Brkt., Left N/C 3610-3412R Width Ext. + 1", pediatric, Right N/C 3610-3422R Page 5 of 6 LifeForm 2"Swing-Away Width and Depth Ext.(optional) Options Available only with Swing-Away Hardware. Width Ext. + 1", 2" Brkt., Right N/C

Choose your bracket and CURVED pad size 3610-3210L E0956 Left 1.5" fixed pediatric bracket LifeForm Fixed Lateral Support Hardware Choose your bracket and PLANAR pad size 3610-3110L E0956 Left 1.5" fixed pediatric bracket Planar Pad 3610-3210R E0956 Right 1.5" fixed pediatric bracket 3610-3110R E0956 Right 1.5" fixed pediatric bracket Planar Pad 3610-3220L E0956 Left 2" fixed bracket lateral thoracic support package, 3610-3120L E0956 Left 2" fixed bracket lateral thoracic support package, Planar Pad 3610-3220R E0956 Right 2" fixed bracket lateral thoracic support package, 3610-3120R E0956 Right 2" fixed bracket lateral thoracic support package, Planar Pad Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Choose a pad size: 3"x4" 4"x4" 4"x5" 4"x6" Accessories Life Support Accessories NOT tested with Transit. Must remove prior to tie down. 3223-6820 K0105 IV Support Pole 3223-6850 E1029 3223-6830 E2208 Oxygen Tank Holder 3223-6840 E1029 Ventilator Tray for LTV Ventilator Series Only Requires 18" Rear Wheels Battery/Vent. Accessory Tray Requires 18" Rear Wheels (Does not include vent. mount for LTV) 3222-6250 Underchair Cargo Tray (carries up to 10lbs) 3223-6600 Rock 3 Sunshade Replacement Contoured Seat Cushion Covers 3229-2231 E2619 14"w x 17"d Seat Cushion Cover Only 3229-3211 E2619 17"w x 17"d Seat Cushion Cover Only 3229-3221 E2619 17"w x 20"d Seat Cushion Cover Only Custom Notes: Additional Extras 3224-2910R 3224-2950R 3224-2980R 3224-7310R 3224-7350R 3224-7380R Upper Body - Soft - Pair Replacement Springs Upper Body - Med - Pair Upper Body - Hard - Pair Lower Body - Soft - Pair Lower Body - Med - Pair Lower Body - Hard - Pair Page 6 of 6

2024 © autodocbox.com Privacy Policy | Terms of Service | Feedback