May 2014 Kids FAST Order Form Maximum Weight Capacity 80 lbs. 12"Wx14.5"Dx19.5"H Seating Capacity. Customer Service: 800-800-8586 (toll free) Email: orders@pridemobility.com Date: Quote Order SHIPPING INFORMATION Provider Acct #: PO#: Provider: Ship To: Provider Contact: Attention: Prov. Address: Address: Provider City: ST: ZIP: Address: Provider Phone: ( ) Fax: ( ) Ship To City: ST: ZIP: Ship To Phone: ( ) Fax: ( ) Confirmation Email: 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 MEASUREMENT WORKSHEET Mark for: Age: in. Height: ft. Weight: lbs. Includes: Adjustable Positioning Shell; Folding Tilt Mobility Base; Quick Release 12" Rear Wheels, 8" Casters; Sunshade, Rear Storage Bag; Frame Color: Silver Metallic (002) Kids FAST Chair, Tilt-in-Space. E1234 Transit Option Back Systems 3224-5210 or 3224-5220 Required to meet ISO Standard 7176-19 3224-5000 ROCK /FAST Chair - Size 1 Transit Option Crash Tested to ISO Standard 7176-19 $2,355.00 $200.00 Upholstery Color Upholstery Color applies to: back; cushions; lateral pelvic/thigh supports; rear storage bag; sunshade; calf protector. Does not apply to reverse Dartex. Vibrant Red/Gray/Black Pink/Gray/Black Blue/Gray/Black REACTION Dynamic Seating A. Sitting Depth B. Trunk Depth C. Trunk Width D. Hip Width E. Top of Shoulder to Seat F. Lower Leg Length Figure 1 - Client Measurements FAST Height Adjustable Activity Base Height Adjustable Activity Base, Seat to floor heaight 13"-21", 40 degree tilt, Available dynamic function,4 locking casters. Height Adj. Base - Dynamic $1,095.00 E2295 REACTION Active Component Upper Body Spring Options Soft - Pair Medium - Pair Hard - Pair No Springs Front Rigging 3224-7120 must be selected when ordering Reaction TM Active Component. Knee angle adjustment in 15 increments with press of button. E0990 Requires 3224-7120 Angle Adjustable Leg Rests 90 Fixed Front Rigging Angle Adj. Elevating Leg Rest Lower Body Spring Options Soft - Pair Medium - Pair Hard - Pair No Springs $695.00 STD $225.00 Page 1 of 5
K0040 90 Fixed Foot Plate Std Inverted Angle Adjustable Foot Plate Std Inverted 35 Dorsal/Plantar Flexion; 10 Positions; 7 increments up /down. Foot Plate Options STD K0040 Angle Adjust Flip-Up Foot Plate Std Inverted Std = 10.5-14" Leg Drop Inverted = 6-10.5" Leg Drop Riser may be substitued in place of inverted foot plate depending upon configuration. Kids UP LifeForm Seat Cushion Options (Choose from A, or B) A. Planar Seat Cushion - Black Mesh Upholstery B. Contoured Seat Cushion - Black Mesh Upholstery E2292 6"-9" Depth $185.00 Includes: 2 Positioning Wedges, Abductor Wedge E2292 8"-11" Depth $185.00 E2294 6"-9" Depth E2292 10"-14" Depth $185.00 E2294 8"-11" Depth E2294 10"-14" Depth Seat Cushion Pressure Relief and Wedges (for A, or B) Pressure Relief Layer: Memory Foam (1/2" thick) $60.00 Anti-Thrust Wedge for Seat Cushion (12" x 6" x 1") $40.00 Contoured Seat Cushion Ischial Inserts (Contoured Only) Open Cell Foam Soft Memory Foam Medium Memory Foam STD $50.00 $50.00 Contoured Seat Cushion Options (Contoured Only) Extra Positioning Wedges (4) $35.00 Synergy Seat Cushion Options E2607 Synergy Solution Cushion 10"x10" E2607 Synergy Solution Cushion 10"x12" E2607 Synergy Solution Cushion 12"x10" E2607 Synergy Solution Cushion 12"x12" E2607 Synergy Solution Cushion 12"x14" Kids UP Lifeform Back Cushion Options (Choose A or B) E2291 A. Planar Back Options B. Contoured I-Back Options Not available with Lateral Thoracic Supports Adjustable Height Back System with Planar Back Cushion $385.00 I-Back Required for Secondary Positioning Accessories; Contoured Back Cushion includes: 4 Contouring Wedges; Lumbar Support E2293 Configurable, Adj. Height I-Back Sys. w/contour Cushion $585.00 Select a Planar Back Cushion 12" - 15" Planar Back Cushion 14" - 19" Planar Back Cushion Omit Planar Back Cushion Less $68 Select a Contoured Back Cushion 11-15" Contour Back Cushion 14-20" Contour Back Cushion Omit Contoured Back Cushion Less $135 Block Letters Back Cushion Embroidery (Emboridery is applied to colored panel) Script Letters Inscription, Please place one letter per box Blue Thread Red Thread Black Thread Green Thread Purple Thread White Thread Page 2 of 5
E0973 Adjustable Height Armrest Thin Profile - Pair Not Available with 3224-5470 - Integrated Pelvic Thigh Supports Armrest Type (Armrest Pad Length = 6") $205.00 E0973 Adjustable Height Armrest for $205.00 Integrated Pelvic/Thigh Supp. Not Available with 3224-5300 - Lateral Pelvic/Thigh Supports Tray Options E0950 Upper Extremity Positioning Platform Color - Clear $128.00 E0950 Upper Extremity Positioning Platform Color - Gray $128.00 Support Hardware - Angle/ Depth Adj. Req. for all trays $144.00 Rear Wheel Selections 3220-1950-D12C 12" Composite Wheels Full Poly STD 3224-4120 Caster Selections 8" x 2" Polyurethane Casters STD Lateral Pelvic/Thigh Supports Left Pelvic/Thigh Support Pkg. $120.00 Left Integrated Pelvic/Thigh Supp.* Right Pelvic/Thigh Support Pkg. $120.00 Right Integrated Pelvic/Thigh Supp.* *Integrated Pelvic/Thigh Supports require Armrest Type 3224-5480 $45.00 $45.00 Lifeform Anterior Pelvic Positioning Belts Medial 4-point belt recommended with REACTION seating. Positioning belts not for use as an occupant restraint during transit in a motor vehicle. E0978 LifeForm 2-point 1" Metal PB Buckle, $88.00 E0978 LifeForm Medial 4-point 1" Metal PB 3.5" pads Buckle, 4.5" pads E0978 LifeForm Medial 4-point 1" Metal PB Buckle, 3.5" pads Lifeform Anterior Trunk Supports Anterior Trunk Supports NOT for use as a occupant restraint during transit in a motor vehicle. LifeForm Contoured Dynamic LifeForm Zipper Opening Dynamic Contoured - Early Intervention Zipper Opening - S Contoured - XS Contoured - S LifeForm Zipper Opening Structured LifeForm Contoured Structured Structured Zipper Opening - S Contoured Structured - S Lifeform Swing-Away Abductor Hardware and Pads 4-way stretch cover included with Lifeform Abductor pads. FAST S/A Abductor Hardware $220.00 Small Wedge(2"-3"W x 4"L x 3"D) Med. Wedge (2"-4.5" x 5"L x 3"D) Lg. Wedge (3"-5" x 5"L x 4"D) E0955 E0955 Lifeform Headrest and Support Hardware 4-way stretch headrest cover is included with headrest pads. 8" Curved Oval Pad $195.00 LifeForm Removable Headrest Mounting Hardware 10" Curved Oval Pad $195.00 (Required for LF Headrest Options) E0955 14" Curved Oval Pad $195.00 Universal Head Rest Mount Plate Only* $50.00 E0955 Narrow Adjustable Arc Pad $280.00 *Accomodates several other manufacturers headrests. Call for details. $215.00 Page 3 of 5
Lifeform Ankle and Foot Positioning Stealth Hard Side Foot Stabilizers Small, Pair, Left and Right $166.00 Medium, Pair, Left and Right $166.00 LifeForm Ankle Hugger Foot Stabilizers Left - Small Right - Small Left - Medium Right - Medium Lifeform Swing Away Lateral Support Hardware Choose your bracket and CURVED pad size Left 1.5" pediatric bracket lateral thoracic support package, Curved Pad Choose your bracket and PLANAR pad size Left 1.5" pediatric bracket lateral thoracic support package, Planar Pad Right 1.5" pediatric bracket lateral thoracic support package, Curved Pad Right 1.5" pediatric 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) Requires 3610-3210 or 3610-3110. Not Available with teardrop laterals. Left 1.5" DoubleSwing pediatric swingaway Right 1.5" DoubleSwing pediatric swingaway Choose Swing-Away Hardware (required) Requires 3610-3210 or 3610-3110. Not Available with teardrop laterals. Left 1.5" DoubleSwing pediatric swingaway Right 1.5" DoubleSwing pediatric swingaway LifeForm Swing-Away Width and Depth Extensions (Optional) Options Available only with Swing-Away Hardware. Depth Ext. + 1", pediatric, Left Depth Ext. + 1", pediatric, Right Width Ext. + 1", pediatric, Left Width Ext. + 1", pediatric, Right Choose your bracket and CURVED pad size Left 1.5" fixed pediatric bracket lateral thoracic support package, Curved Pad Lifeform Fixed Lateral Support Hardware Choose your bracket and PLANAR pad size Left 1.5" fixed pediatric bracket lateral thoracic support package, Planar Pad Right 1.5" fixed pediatric bracket lateral thoracic support package, Curved Pad Right 1.5" fixed pediatric 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" Page 4 of 5
Additional Support Accessories E1029 O2 holders and tanks are NOT tested with Transit and must be removed prior to tie down. Battery/Accessory Tray* Ventilator Holder/Battery Tray* for LTV Ventilator Series Only. $360.00 $440.00 E2208 Oxygen Tank Holder K0105 IV Support Pole * Battery/Accessory Tray and Ventilator Holder/Battery Tray require special frame configuration and are not retrofitable Accessories Misc. Accessories Replacement Springs Bottom Storage Carrier (not available with Vent or Accessory Tray) $125.00 Upper Body - Soft - Pair Upper Body - Med - Pair Contoured Seat Cushion Covers Upper Body - Hard - Pair Cover Only - 6" - 9" Lower Body - Soft - Pair Cover Only - 8" - 11" Lower Body - Med - Pair Cover Only - 10" - 14" Lower Body - Hard - Pair Planar Seat Cushion Covers Cover Only - 6" - 9" Cover Only - 8" - 11" Cover Only - 10" - 14" Custom Notes: Page 5 of 5