JAY AES - QUICK ORDER FORM November 2012 Account: Date: Job #/PO#: User Name: Contact: Ship To: Name: Address: City,State,Zip: Phone: 1. WHEELCHAIR INFORMATION (REQUIRED) 3. SEAT DIMENSIONS Model: Model: Insert Measurements For Figure 3.1 in the Circles Provided Color: Tubing Size 3/4" 7/8" 1" Seat Back Frame Width: Depth: Push Handle Ht: Chair Type: Manual Power Installation: To Frame MOD6800LK (Manual Chair) Install Transport Option Hardware Hinges: Flush Bk to Seat Offset Bk to Seat 1.5" 3" Adj. Full Width Mount: Back Seat Btwn Rail Mount: Back Seat Monogram: MOD5900 BLOCK MOD5901 SCRIPT Name: Thread Color: Client Contact Surface: Client Contact Color: A. Seat Width E, Usable Seat Depth Non-contact Surface: (Std) Black Other (specify) B. Back Width F. Seat Depth Naugahyde C. Distance Between Thoracic Laterals G. Back Height 2. CLIENT MEASUREMENTS D. Distance Between Pelvic Laterals H. Seat to Top of Lateral Thoracic Pa Insert Measurements For Figure 2.1 in the Circles Provided Figure 3.1 - Seat Dimensions PAGE 1 NOTES: A. Shoulder Width G. Seat to AXILLA B. Chest Width H. Seat to PSIS C. Hip Width I. Chest Depth D. Width at Knee J. Back to Anterior of IT's E. Seat to TOP of head K. Seat Depth F. Seat to TOP of Shoulder L. Seat to Foot Plate Figure 2.1 - Client Measurements Page 1
JAY AES - QUICK ORDER FORM November 2012 5. SEATING SYSTEM PACKAGES All packages include seat insert, back insert and connecting hinges (hardware specified below). For systems 14" wide or smaller, please refer to the Li'l Kiddos TM Order Form. PKG10XX PKG11XX PKG13XX PKG20XX PKG23XX PKG30XX SSK20XX SSK21XX SSK60XX $1,053.75 $1,042 $1,042 Description Solid Seat w/universal Mount; E-Z Mount Hardware $569.25 Solid Seat; Adj. J Hook & Rotating Hold Downs (Full Width) $348.75 SSK30XX Solid Seat; E-Z Mount Hardware $463.25 Solid Seat w/flush, 1",2", or 3" SSK50XX Drop Hook & Rotating Hold Downs (Btwn Rails) $286.25 SSK55XX Description Connecting Hinges; Universal Back Mount; E-Z Mount Hardware Connecting Hinges; Adjustable Drop Hook Hardware; Drop Stops 6. SOLID SEAT PACKAGES SSK10XX Connecting Hinges; Universal Back and Seat Mounting Hdwr Connecting Hinges; Space Saver Universal Back and Seat Mount Hardware Connecting Hinges; Adjustable Flush Hook/J Hook Hardware Connecting Hinges; E-Z Mount Hardware; Drop Stops Solid Seat; Adj. J Hook & Rotate Hold Downs (Btwn Rails) Solid Seat w/flush Hooks & Rotating Hold Downs (Full Wid.) Solid Seat w/flush, 1",2", or 3" Drop Hook & Fixed Hold Downs (Btwn Rails) $787.50 $800.25 $972 Quote $327.50 $286.25 7. SOLID BACK PACKAGES Description To SBK10XX Sold Back W/Universal Hardware $674.25 Sold Back w/adjustable J Hook & SBK20XX Fixed/Rotating Hold Downs (Forward) $360.50 Sold Back w/adj. J Hook & Fixed SBK21XX Hold Downs (Forward) $348.75 Sold Back w/adjustable J Hook & SBK22XX Fixed/Rotating Hold Downs (Between Uprights) $360.50 Sold Back w/adjustable J Hook & SBK23XX Fixed Hold Downs (Between Uprights) $348.75 Sold Back w/ E-Z Mount SBK25XX Hardware & Rotating Hold Downs $533.25 8. SEAT MODIFICATIONS Description MOD1200 2" HR Foam in Seat MOD1400 1" Pudgee Foam MOD1800 1" SunMate Foam MOD1815 MOD4150 MOD4200L MOD4200R MOD4300 MOD4400 MOD4600 MOD4700 MOD5000 PAGE 2 NOTES: Seat Notches Back Post 2"x2" if other specify x Offset Seat - Right $198.25 $67.75 $84.75 N/C $89 $89 "T" Style Seat $94.25 $134 MOD4800 Seat Rail Foam Overlay $106 MOD9050 MOD9075 1 1/2" SunMate Foam Offset Seat - Left Anti-Thrust Shelf Height Depth Contour Seat Built-In Medial Thigh Support "I" Style Seat $96.50 Oversized Seats over 20" up to 24" Oversized Seats over 24" up to 28" $25.50 $135.75 $272.50 $63.50 $83.75 To Page 2
JAY AES - QUICK ORDER FORM November 2012 9. BACK MODIFICATIONS 11. LATERAL THORACIC PAD MODIFICATIONS Description NOTE: Thoracic Support Packages are priced as EACH; Order 2 for a pair. MOD2200 2" HR Foam in Seat $25.50 MOD2400 1" Pudgee Foam $198.25 Description To MOD2800 1" SunMate Foam $67.75 MOD2550 1/4" Gel In Support $38.25 MOD2815 1 1/2" SunMate Foam $84.75 MOD2850 1/2" SunMate in Support STD MOD4645L Lateral Reinforcement - Left $86 MOD3000 Replc. Multi-ply w/ ABS $9.50 MOD4645R Lateral Reinforcement - Right $86 MOD3150 Contour Fit $49.75 MOD5180 Foam Form Back $362 MOD5510 Curved Pad $16 MOD5200 "I" Style Back $96.50 MOD5300 "T" Style Back $96.50 12. HEAD SUPPORT PACKAGES MOD5450 MOD5460 MOD5500 MOD5550 MOD5800 MOD9150 MOD9175 Adjustable Angle, Bi-Angular Bottom H Top H Adjustable Lumbar Back Apex: Curved Back Cubed Back Contour Back Oversized Backs over 20" up to 24" Oversized Backs over 24" up to 28" 10. LATERAL THORACIC SUPPORT PACKAGES $272.50 $294.75 $133.50 $323.25 $237.50 $63.50 $83.75 NOTE: Thoracic Support Packages are priced as EACH; Order 2 for a pair. NOTE: Flat pad standard on all packages. Please indicate size and shape preference under Pad Specifications. Additional charges apply. Whitmyer Cobra Xtra with Lycra Cover Description COBRA-P3L 8" Plush Pad,Cobra Xtra Mnt $417 COBRA-P1L 10" Plush Pad,Cobra Xtra Mnt $417 COBRA-P12L COBRA-P2L COBRA-AP1L COBRA-AP2L 12" Narrow Plush Pad Cobra Xtra Mnt 14" Plush Pad,Cobra Xtra Mnt Narrow Adj. a Plush Pad Cobra Xtra Mnt Standard Adj. a Plush Pad Cobra Xtra Mnt Select Head Support Vertical/Horizontal Mount Size: $440 $447 $547 $547 Pediatric Adult Early Intervention To Description Thoracic Support Pkg.: Std. LTK22XX $138.75 Alum. Bracket, Pad, Adj. Rail LTK24XX Thoracic Support Pkg.: Med/ High Prof. Brckt, Pad, Adj. Rail $138.75 Thoracic Support Pkg.: EZ LTK25XX Access Swing-Away Bracket, $268.25 Pad, Adj. Rail PAGE 3 NOTES: LTK35XX LTK37XX Thoracic Support Pkg.: Rear Quick Adj. Only Bracket, Pad, Adj. Rail Thoracic Support Pkg.: Rear Quick Adj. and EZ Access Swing Away Bracket, Pad, Adj. Rails $286.25 $332.75 Lateral Thoracic Pad Specifications Pad Size: 3x4 4x5 5x6 Other: H: x D Pad Shape: Flat (std) Curved Tapered Contour (Specify Contour Shape and Profile Below) Profile: Tear D Shape: Curved Flat Page 3
JAY AES - QUICK ORDER FORM November 2012 13. LATERAL PELVIC/THIGH SUPPORT PACKAGES 16. MEDIAL THIGH SUPPORT MODIFICATIONS NOTE: Packages are priced as EACH; Order 2 for a pair. NOTE: Pad size up to 5"H x 18"L, specify below. NOTE: Thigh modifications are priced as EACH; Order 2 for a pair. Description Description To LPK22XX Std. Bracket and Pad $116.50 MOD3555 1/4" Gel in Medial Support $101.75 LPK32XX Med/Thigh Profile Brckt & Pad $116.50 MOD3655 1/2" "T" Foam in Medial Support $28.50 LPK27XX Removable Bracket & Pad $251.25 MOD3755 1/2" Pudgee in Medial Support $101.75 LPK33XX 20 Adj. Bracket & Pad $288.25 MOD3855 1/2" SunMate in Medial Support Std LPK57XX 20 Adj. w Fixed Brckt & Pad $220.50 LPK55XX 1" Reverse Offset Brckt & Pad $140 Lateral Pelvic/Thigh Support Pad Specifications Pad Size: H D 14. LATERAL PELVIC/THIGH PAD MODIFICATIONS NOTE: Lateral Pelvic/Thigh pad modifications are priced as EACH; Order 2 for a pair. Description MOD3055 Contour for Anti-Thrust $39.25 MOD3551 1/4" Gel in Pelvic Support $45.50 PAGE 4 NOTES: MOD3750 1/2" Pudgee in Pelvic Support $41.25 MOD3850 1/2" SunMate in Pelvic Support Std 15. MEDIAL THIGH SUPPORT PACKAGES NOTE: Medial Support Packages priced as EACH; Order 2 for a pair. Description MTK50XX Adj. Ht. Swing Away Bracket 2" to 3" $425 MTK60XX MTK70XX Adj. Ht. Swing Away Bracket 3" to 4.5" Hideaway Bracket "L" Mount 1.5" to 3" $425 $518.25 MTK74XX Adj. Ht. Hideaway Brckt-Short $546 MTK76XX MTK93XX Adj. Ht. Hideaway Brckt-Tall Pull Away Bracket Adjusts 1 1/2" to 2" $546 $445.25 MTK95XX MTK97XX Pull Away Bracket Adjusts 2" to 3 1/2" Pull Away Bracket Adjusts 3 1/2" to 5 1/2" $445.25 $445.25 Medial Thigh Support Specifications Pad Size: Small Medium Large Page 4
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