CUSTOM INCEPTION CUSHION ORDER FORM HCPC CODE: E2609

CUSTOM INCEPTION CUSHION ORDER FORM HCPC CODE: E2609 CUSTOMER/PATIENT INFORMATION Date: Company Name/ACCT #: Patient Name: Patient Weight: Patient Height: P.O. Number: Requested By: Phone: Email: Ship To: Fax: W/C Manufacturer: Model #: Serial #: Additional Information: Seat Frame Width: Seat Frame Depth: Seat Rail Tube Size: SEATING SYSTEM MEASUREMENTS G A Seating system measurements do not affect any selections made through the order form. B A - Back Width H B - Width Between Laterals C - Width Between Hip Guides D - Seat Width C E - Actual Seat Depth F - Total Seat Depth G - Back Height from Top of Cushion H - Lateral Height from Top of Cushion E D F Overall Height: Overall Weight: S E A T I N G 509 S. 22ND AVENUE BOZEMAN, MT PH. 800.564.9248 FAX. 406.522.8563 WWW.COMFORTCOMPANY.COM 1/7

1 CUSTOM CUSHION SIZE & COVER MATERIAL 1.1 SEAT/CUSHION SIZE Select desired cushion size using the sizing chart below or fill The size and shape of the cushion must be selected in Sections 1.1 and 2.1 to determine the price of the cushion. Select the desired cushion size by clicking/circling the correct size below or fill in the specific width and height in measurements the specific width in the and Other depth Part in Number the custom Box. part number box. A cushion shape in Section 2.1 must be selected. The selected shape may be modified by continuing through the form. WIDTH DEPTH MSRP $87.00 UP CHARGE 22 20 C-C-10W22D C-C-11W22D C-C-12W22D C-C-13W22D C-C-14W22D C-C-15W22D C-C-16W22D C-C-17W22D C-C-18W22D C-C-19W22D C-C-20W22D C-C-21W22D C-C-22W22D C-C-23W22D C-C-24W22D C-C-25W22D C-C-26W22D C-C-27W22D C-C-28W22D C-C-10W21D C-C-11W21D C-C-12W21D C-C-13W21D C-C-14W21D C-C-15W21D C-C-16W21D C-C-17W21D C-C-18W21D C-C-19W21D C-C-20W21D C-C-21W21D C-C-22W21D C-C-23W21D C-C-24W21D C-C-25W21D C-C-26W21D C-C-27W21D C-C-28W21D C-C-10W20D C-C-11W20D C-C-12W20D C-C-13W20D C-C-14W20D C-C-15W20D C-C-16W20D C-C-17W20D C-C-18W20D C-C-19W20D C-C-20W20D C-C-21W20D C-C-22W20D C-C-23W20D C-C-24W20D C-C-25W20D C-C-26W20D C-C-27W20D C-C-28W20D C-C-10W19D C-C-11W19D C-C-12W19D C-C-13W19D C-C-14W19D C-C-15W19D C-C-16W19D C-C-17W19D C-C-18W19D C-C-19W19D C-C-20W19D C-C-21W19D C-C-22W19D C-C-23W19D C-C-24W19D C-C-25W19D C-C-26W19D C-C-27W19D C-C-28W19D 18 C-C-10W18D C-C-11W18D C-C-12W18D C-C-13W18D C-C-14W18D C-C-15W18D C-C-16W18D C-C-17W18D C-C-18W18D C-C-19W18D C-C-20W18D C-C-21W18D C-C-22W18D C-C-23W18D C-C-24W18D C-C-25W18D C-C-26W18D C-C-27W18D C-C-28W18D SEAT DEPTH UP CHARGE 16 14 12 C-C-10W17D C-C-11W17D C-C-12W17D C-C-13W17D C-C-14W17D C-C-15W17D C-C-16W17D C-C-17W17D C-C-18W17D C-C-19W17D C-C-20W17D C-C-21W17D C-C-22W17D C-C-23W17D C-C-24W17D C-C-25W17D C-C-26W17D C-C-27W17D C-C-28W17D C-C-10W16D C-C-11W16D C-C-12W16D C-C-13W16D C-C-14W16D C-C-15W16D C-C-16W16D C-C-17W16D C-C-18W16D C-C-19W16D C-C-20W16D C-C-21W16D C-C-22W16D C-C-23W16D C-C-24W16D C-C-25W16D C-C-26W16D C-C-27W16D C-C-28W16D C-C-10W15D C-C-11W15D C-C-12W15D C-C-13W15D C-C-14W15D C-C-15W15D C-C-16W15D C-C-17W15D C-C-18W15D C-C-19W15D C-C-20W15D C-C-21W15D C-C-22W15D C-C-23W15D C-C-24W15D C-C-25W15D C-C-26W15D C-C-27W15D C-C-28W15D C-C-10W14D C-C-11W14D C-C-12W14D C-C-13W14D C-C-14W14D C-C-15W14D C-C-16W14D C-C-17W14D C-C-18W14D C-C-19W14D C-C-20W14D C-C-21W14D C-C-22W14D C-C-23W14D C-C-24W14D C-C-25W14D C-C-26W14D C-C-27W14D C-C-28W14D C-C-10W13D C-C-11W13D C-C-12W13D C-C-13W13D C-C-14W13D C-C-15W13D C-C-16W13D C-C-17W13D C-C-18W13D C-C-19W13D C-C-20W13D C-C-21W13D C-C-22W13D C-C-23W13D C-C-24W13D C-C-25W13D C-C-26W13D C-C-27W13D C-C-28W13D C-C-10W12D C-C-11W12D C-C-12W12D C-C-13W12D C-C-14W12D C-C-15W12D C-C-16W12D C-C-17W12D C-C-18W12D C-C-19W12D C-C-20W12D C-C-21W12D C-C-22W12D C-C-23W12D C-C-24W12D C-C-25W12D C-C-26W12D C-C-27W12D C-C-28W12D C-C-10W11D C-C-11W11D C-C-12W11D C-C-13W11D C-C-14W11D C-C-15W11D C-C-16W11D C-C-17W11D C-C-18W11D C-C-19W11D C-C-20W11D C-C-21W11D C-C-22W11D C-C-23W11D C-C-24W11D C-C-25W11D C-C-26W11D C-C-27W11D C-C-28W11D 10 C-C-10W10D C-C-11W10D C-C-12W10D C-C-13W10D C-C-14W10D C-C-15W10D C-C-16W10D C-C-17W10D C-C-18W10D C-C-19W10D C-C-20W10D C-C-21W10D C-C-22W10D C-C-23W10D C-C-24W10D C-C-25W10D C-C-26W10D C-C-27W10D C-C-28W10D 10 12 14 16 18 20 22 24 26 28 MSRP $66.00 MSRP $418.00 UP CHARGE UP CHARGE UP CHARGE FRAME WIDTH - OR - 1.2 COVER MATERIAL OPTIONS STRETCH AIR Select a fabric type. COMFORT TEK OTHER PART NUMBER BOX: If the desired size is not listed in the chart above please fill in these blank spaces with the required width and depth measurements. Then send this form to Customer Service for pricing. Fax 406.522.8563 or customerservice@comfortcompany.com SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION. PROVIDES NO INCONTINENCE PROTECTION. STRETCH AIR - OR - SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE. COMFORT TEK Custom Back Part Number: C - C - W D 2/10

2 CUSTOM CUSHION SPECIFICATIONS 2.1 CUSTOM CUSHION SHAPE A Common Cushion Specification or Build To Specification cushion must be selected. Proceed to Section 2.2 and beyond to modify ANY part of the selected cushion. For other than the listed shapes please contact Customer Service 800.564.9248. BUILD TO SPECIFICATION MSRP 350.00 Proceed to Section 2.2 if selected. No common cushion specifications will be applied to the cushion if Build to Specification is selected.? Build to Specification All desired build features beginning in Section 2.2 must be selected when Build to Specification is selected. - OR - COMMON LINEAR SPECIFICATIONS: Cushion will come with: - Flat Bottom with ¼ Crosslink -1 HR Medium Lower Layer -½ HR Soft Middle Layer -½ Visco Soft Topper Layer LINEAR MSRP $275.00 If linear is selected, Anti-Thrust, abduction and adduction features may NOT be selected later in the form. If these features are needed, select a different Common Specification Cushion below or use the Build To Specification option above. Common Linear Specifications COMMON CUSHION SPECIFICATIONS (CCS) COMMON LINEAR ANTI-THRUST SPECIFICATIONS: Cushion will come with: - Flat Bottom with ¼ Crosslink -1 HR Medium Lower Layer -½ HR Soft Middle Layer -1 High Anti-Thrust that is ½ the total depth of the cushion. -½ Visco Soft Topper Layer COMMON ZERO ELEVATION CONTOUR SPECIFICATIONS: Cushion will come with: - Flat Bottom with ¼ Crosslink -1 HR Medium Lower Layer -½ HR Soft Middle Layer -1½ H Adductors -1½ H Abductor -½ Visco Soft Topper Layer ANTI-THRUST MSRP $350.00 Common Linear Anti-Thrust Specs ZERO ELEVATION CONTOUR MSRP $350.00 Common Zero Elevation Contour Specs If Anti-Thrust is selected, abduction and adduction features may NOT be selected later in the form. If these features are needed, select a different common cushion below or use the build to specification option above. If Zero Elevation Contour is selected, Anti- Thrust features may NOT be selected later in the form. If these features are needed, select a different Common Specification Cushion below or use the Build To Specification option above. COMMON ANTI-THRUST CONTOUR SPECIFICATIONS: Cushion will come with: - Flat Bottom with ¼ Crosslink -1 HR Medium Lower Layer -½ HR Soft Middle Layer -1 High Anti-Thrust that is ½ the total depth of the cushion. -1½ H Adductors -1½ H Abductors -½ Visco Soft Topper Layer ANTI-THRUST CONTOUR MSRP $350.00 Common Anti-Thrust Contour Specs If Anti-Thrust Contour is selected, any of the features may be modified. If other features are needed choose the Build to Specification option above. 3/10

2.2 CUSHION PLATFORM Multiple selections from this section are available. If nothing is selected, Cushion Only will be provided. CUSHION ONLY REMOVABLE SOLID SEAT PAN & HARDWARE MSRP $375.00 When cushion only is selected, no platform will be included. Cushion Only The solid seat pan includes a slotted aluminum pan and attaching hardware to accommodate 7/8 or 1 tubing. Hip guides can be easily attached. Removable Solid Seat & Hardware RIGID INSERT MSRP $61.00 MOLDABLE INSERT MSRP $140.00 3/16 Plastic rigidizing board. Rigid Insert Glued Moldable aluminum enables on-site customization to the contour of the cushion. ¼ Crosslink is not recommended with this insert and will not be included if a Common Specification Cushion is selected. Moldable Insert Rigid Insert Not Glued 2.3 BOTTOM STYLE Multiple selections from this section are available. If nothing is selected, Flat Bottom will be provided. FLAT BOTTOM WEDGE Flat Bottom is standard if no bottom style is selected. Flat Bottom If a wedge bottom is selected, an HR Medium foam wedge is glued to the bottom of the lower layer of foam. The specified thickness of the wedge will alter the front height of the cushion and may affect the seat to floor height measurement of the chair. A SIDE VIEW WEDGE HEIGHT A = 1 H A = 2 H A = 3 H If a flat bottom with rail cuts is selected, a standard 1 ½ wide cut will be made and you will select how high the cut will need to be. All cuts run the entire depth of the cushion to lower overall cushion height once placed on the chair. FLAT BOTTOM W/RAIL CUTS 1½ B = 1 H Rail Cut B = 1½ H Rail Cut B = 2 H Rail Cut B If a round bottom style is selected, a round contoured HR Medium foam is glued to the bottom layer of foam. ½ to 1 of additional profile height will be added to the cushion. ROUND BOTTOM Round Bottom 4/10

2.4 GROWTH NOTCHES 2.5 COCCYX CUT OUT DEPTH OF NOTCHES COCCYX CUT OUT If growth notches are selected, a 1¼ wide cut will be taken from each side to allow the cushion to fit between the back canes. TOP VIEW 1¼ C Coccyx cut out will be cut in the lower layer. SIZE Coccyx Cut Out C = 1 D C = 2 D C = 3 D Other 2.6 HAMSTRING RELIEF 2.7 LEG LENGTH DISCREPANCY DEPTH OF RELIEF DEPTH OF DISCREPANCY MSRP $75.00 Hamstring relief will cause the bottom of the cushion to be more shallow than specified seat depth. D SIDE VIEW SIZE D = 1 D D = 2 D Other The width of the cut out is half the cushion width unless Notch for Abductor Hardware is selected below. The specified discrepancy reduces the depth of the cushion on the specified side. LEFT SIDE DISCREPANCY CENTER LINE L DEPTH REMOVED FROM SIDE R E = ½ D E = 1 D CENTER LINE R L R L E E RIGHT SIDE DISCREPANCY E = 1½ D E = 2 D Other - AND/OR - NOTCH FOR ABDUCTOR HARDWARE The width of the longer side will be 1½ wider than half of the width of the cushion. LEFT SIDE DISCREPANCY CENTER LINE RIGHT SIDE DISCREPANCY CENTER LINE R L R L 1½ 1½ Allow for Abductor Attachment 5/10

3 3.1 CUSTOM CUSHION GEOMETRY ANTI-THRUST Select height and depth for desired Anti-Thrust by filling out Sections A & B. Anti-Thrust shelf is made with an HR Medium foam that is glued to the top side of the middle foam layer. A. F ANTI-THRUST HEIGHT B. ANTI-THRUST DEPTH Anti-Thrust growth kit will come with 3-1 deep strips, which will allow for growth of the Anti- Thrust shelf. The top layer of foam will not be glued in the seat well. A zippered pocket at rear of cushion cover is included to store the three strips. ANTI-THRUST SIDE VIEW F = ½ H F = 1 H F = 1 ½ H F = 2 H F = 2 ½ H Other Anti-Thrust Growth Kit G ANTI-THRUST SIDE VIEW G = 4 D G = 11 D G = 5 D G = 12 D G = 6 D G = 13 D G = 7 D G = 14 D G = 8 D G = 15 D G = 9 D G = 16 D G = 10 D Other 3.2 ABDUCTION 3.3 ADDUCTION Select an abductor height for specific cushion contour. Select an adductor shape for specific cushion contour in Section A, and select an Adductor height in Section B. Abductor insert is made of HR Medium foam and glued to the top of the middle layer of foam. RIGHT ABDUCTOR HEIGHT H LEFT If omit Adductor in Seat Well is selected, adductors will not be built into the rear half of the cushion. Tapered adductors are designed to off load the Ischial Tuberosities by loading the Greater Trochanters. A. ADDUCTOR STYLE REAR Adductor insert is made of HR Medium foam and glued to the top of the middle layer of foam. B. K ADDUCTOR HEIGHT RIGHT VIEW LEFT J VIEW RIGHT ADDUCTOR LEFT ADDUCTOR ABDUCTOR WEDGE No Abductor H = ½ H H = 1 H H = 1 ½ H Standard H = 2 H H = 2 ½ H Specify Custom Height Standard Adductor Tapered Adductor Omit Adductor in the Seat Well Standard Tapered Area Adduction Removed J Left Leg Adduction Right Leg Adduction K None J = ½ H J = 1 H J = 1 ½ H Standard J = 2 H J = 2 ½ H Specify Custom Height None K = ½ H K = 1 H K = 1 ½ H Standard K = 2 H K = 2 ½ H Specify Custom Height 6/10

4 4.1 CUSTOM FOAM SELECTION CUSTOM FOAM SELECTION Select any combination of Lower, Middle, and Topper Layers. A minimum of one layer must be chosen, when Build to Specification is selected. CCS = Custom Cushion Specification A colored square must be selected if gel pack in Section 5.1 is desired. For other foam combinations call Customer Service 1.800.564.9248. LOWER LAYER (REQUIRED) H.R. VISCO MSRP $100.00 MIDDLE LAYER H.R. VISCO MSRP $100.00 TOPPER LAYER H.R. VISCO MSRP $100.00 MSRP $0.00 Cushion contours will be placed between the two top most layers. If only one layer is selected, ¼ crosslink will be added to the bottom of the cushion. FOAM TYPE H.R. Medium H.R. Soft CROSS LINK LOWER LAYER MIDDLE LAYER TOPPER LAYER ¼ ½ ¾ 1 1¼ ¼ ½ ¾ 1 1¼ ¼ ½ ¾ 1 1¼ CCS CCS MSRP $100.00 MSRP $0.00 Visco Medium Visco Soft Visco X-Soft Visco XX-Soft Crosslink (Optional) CCS 5 5.1 ISCHIAL MODIFICATIONS ISCHIAL MODIFICATION Ischial inserts are cut into the mid layer below the topper layer. Includes four individual gel filled compartments that prevent the migration gel under the seated surface. A minimum of ¾ middle layer is required for this insert. The cushion must be at least 16 W and 16 D to use the QuadraGel Option. ISCHIAL QUADRAGEL INSERT MSRP $65.00 Ischial QuadraGel Insert Includes two individual gel filled compartments that prevent the migration of the gel under the seated surface. The cushion must be at least 16 W and 12 D to use the Ischial Gel Insert Option. ISCHIAL GEL INSERT MSRP $50.00 Ischial Gel Insert ISCHIAL SUNMATE INSERT MSRP $45.00 The specified type of Sunmate helps distribute ischial and sacral pressures. A minimum of a 1 middle layer is required. 1 Thick Soft Sunmate 1 Thick X-Soft Sunmate 7/10

5.2 ISCHIAL RECESS Determine if a full length or rear quadrant is necessary. Select a right or left side of the desired amount of recess. The amount of recess must match or be thicker than the middle foam layer. A topper layer must be selected with this option. R REAR QUADRANT RECESS MSRP $115.00 L R L The amount of recess must match or be thicker than the middle foam layer. A topper layer must be selected with this option. R FULL LENGTH RECESS MSRP $115.00 L R L L LEFT SIDE RIGHT SIDE R ½ H ½ H 1 H 1 H 1.25 H 1.25 H L LEFT SIDE RIGHT SIDE R ½ H ½ H 1 H 1 H 1.25 H 1.25 H 6 CUSHION ACCESSORIES 6.1 COLOR 6.2 PRIVACY FLAP Accent colors can be applied to the cushion via colored piping. If no colors are selected, no piping will be stitched onto the cushion. This flap connects with hook/loop between the seat and back for added privacy. COLOR LOCATION Red Blue Purple Green Pink Silver Privacy Flap 6.3 ZIPPERED POUCH 6.4 EXTRA COVERS & INCONTINENCE LINER MSRP $80.00 Zippered pouch is sewn into the front of the cushion. Incontinence Liner provides extra incontinence protection for the cushion. The zippered liner may be used as an extra cover when the outer cover is being washed. Zippered Pouch Incontinence Liner Extra Strech Air Outer Cover Extra Comfort Tek Outer Cover 8/10

7 HIP GUIDELINES & HARDWARE 7.1 HIP GUIDES HCPC Code: E0956 RIGID MSRP $50.00/ea Select a left and/or right Hip Guide using ANY combination of both style/fabric. Contact Customer Service for custom sizes that are not listed below. 1.800.564.9248. RIGID CONTOURED for Anti-Thrust Cushion MSRP $50.00/ea T-Nut spacing along hip guide is 1 on center running the entire length of the pad. H D H D STRETCH AIR SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION. PROVIDES NO INCONTINENCE PROTECTION. STRETCH AIR FABRIC Add l L L SIZE R Add l R 3 H x 4 D 3 H x 5 D 4 H x 4 D 4 H x 6 D 4 H x 8 D 4 H x 10 D 4 H x 12 D 4 H x 14 D 4 H x 16 D STRETCH AIR FABRIC Add l L L SIZE R Add l R 3 H x 4 D 3 H x 5 D 4 H x 4 D 4 H x 6 D 4 H x 8 D 4 H x 10 D 4 H x 12 D 4 H x 14 D 4 H x 16 D - OR - - OR - COMFORT TEK SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE. COMFORT TEK FABRIC Add l L L SIZE R Add l R 3 H x 4 D 3 H x 5 D 4 H x 4 D 4 H x 6 D 4 H x 8 D 4 H x 10 D 4 H x 12 D 4 H x 14 D 4 H x 16 D COMFORT TEK FABRIC Add l L L SIZE R Add l R 3 H x 4 D 3 H x 5 D 4 H x 4 D 4 H x 6 D 4 H x 8 D 4 H x 10 D 4 H x 12 D 4 H x 14 D 4 H x 16 D 7.2 HIP GUIDE HARDWARE HCPC Code: E0956 A. WIDTH ADJUSTABLE BRACKETS B. ADDITIONAL LINK MSRP $100.00/ea MSRP $35.00/extra link Hip guide hardware will allow for width adjustability. Brackets come standard with 2 links in Section A. Each additional link adds 1 of height. Extra linkage is available for more adjustability in Section B. 5 LEFT 5 RIGHT 1 LEFT RIGHT (1) Add l L (1) Add l R (1) Add l L (1) Add l R (2) Add l L (2) Add l R (2) Add l L (2) Add l R (3) Add l L (3) Add l R 9/10

8 ADDITIONAL INFORMATION 8.1 COMMENTS Please reference any section or subsection of the form when commenting. Section # Page # COMMENTS If preferred, please sketch ideas in the spaces provided below. ADDITIONAL NOTES HERE: ADDITIONAL NOTES HERE: 10/10