JAY SureFit. AES Lite - Custom Seating
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- Blake Atkins
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1 ST: Dealer Phne: ( ) Fax: ( ) Diagnsis Height Weight 7. Width f Head Style Stck Mngram Design lr T-Nut Lcatin mbine with Wheelchair hair Width nfirm Via: 4. Trunk Depth 5. Actual Sitting Depth* 6. Ft Length 9. hest Width 10. Hip Width* ack Height Name Seat Rail Diameter hair Depth Date: Dealer Acct #: Dealer Address: First Name Age Mark Fr: 2. Tp f Shulder t Seat* 3. Under Arm t Seat 8. Shulder Width 12. Right Lwer Leg Length* Mdel Dealer: Dealer ntact: Dealer ity: nfirmatin 1. Tp f Head t Seat 11. Left Lwer Leg Length* ustm Embridery (12 Ltr Limit) Upper ack ane Diameter Lwer ack ane Diameter ZIP: Nw knwn as Fax Ship T Phne: ( ) Fax: ( ) lient Wheelchair Descriptin Script/ursive lck/uppercase D Nt Mark Existing hair Serial # 7/8" 1" 1" 1 1/8" AES Lite - ustm Seating See Quickie/Zippie OF 3/4" 7/8" 1" lck/lwercase 0677Z01 067XL03 1 1/8" 067XL03 7/8" JAY SureFit Nvember 2015 LIENT MEASUREMENTS 0677Z01 067XZ01 067XZ02 067XL03 067XL01 067XL02 067XQ02 067XQ01 067XQ03 Ntes Submitting fr: PO#: Ship T: Attentin: Address: Address: Ship T ity: Qute ST: Seating Specificatins A. Seat Width D. ack Width E. ack Height. Seat Depth (Ttal) Order ADDITIONAL SHIPPING INFORMATION. Seat Depth (Usable) F. Width etween Laterals G. Width etween Hips ustmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. pyright 2015 Sunrise Medical (US) LL. JAY SURE FIT / AES Lite, MK REV. Page 1 ZIP:
2 AKREST ack Style 067YS01 Planar ack $ YS04 Omit ver Optins 067YU01 Standard Zipper Access ver N/ 067YU04 Remvable Zipper Access ver $ * Fam Thickness Only ack Misc. 067YT05 Tw Piece ushin & ase ack $ Nt Available with Adjustable Lumbar AK MODIFIATION - E2617 Nte: Mdificatins retail is added t the price f the Planar ack 067YS08 urved Wd ack $ YS12 Adjustable Lumbar Supprt $ * Fam Thickness Only * Fam Thickness Only D** ** Minimum Length is 3.5" E Nt Available with urved Fam, ube ack, Adj Lumbar, & Lumbar Nt Available with urved ack, ube ack, i-angular, & Lumbar 067YS02 urved Fam ack $ YT02 iangular Mdificatin $ * Fam Thickness Only * Fam Thickness Only N/A w/quickie TS Snap 2 r 4 Pin Nt Available with urved Wd, ube ack, & Adj Lumbar Nt Available with urved Wd & Adj Lumbar 067YT04 I ack Mdificatin $ YS07 ube ack $ * Fam Thickness Only * Fam Thickness Only D Nt Available with Adjustable Lumbar 067YT03 T ack Mdificatin $ YS06 Lumbar with r withut Straps $ * Fam Thickness Only * Fam Thickness Only ** With Straps (External) **Minimum length is 3" Withut Straps (Internal) Nt Available with Quickie TS 2 r 4 Pin Hardware Nt Available with urved Wd ackrest AK UPHOLSTERY Nte: Visit fr a full list f clrs available. ntact Surface Nn-ntact Surface 067ZD22 Rubatex - lack 067ZD31 Rubatex - lack 067ZD01 Naugahyde/Vinyl 067ZD32 Naugahyde/Vinyl lr: lr: 067ZD29 Dartex - lack 067ZD48 Dartex - lack 067ZD30 Reverse Dartex - lack 067ZD49 Reverse Dartex - lack ustmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. pyright 2015 Sunrise Medical (US) LL. JAY SURE FIT / AES Lite, MK REV. Page 2
3 067ZF06 067ZF07 Snaptite 1" STD** Snaptite 1 1/2" Drp Snaptite 3" Drp Quickie TS Snap 2 pin Quickie TS Snap 4 pin** ack Hardware Jay 3 ack Style Shrt w/ bracket Jay 3 ack Style Lng w/ bracket Universal Transit Hardware** Adjustable J&L (J-2 Hle & L-6 Hle) Std Adjustable J&L (J-6 Hle & L-2 Hle) Adjustable J&L (Std) w/ Shurlck Rel/Fixed Adjustable J&L (Std) w/ Shurlck Release Omit ack Hardware Seat t ack Hardware racket STD Flush (Pr) racket Adjustable Wide AK HARDWARE - E2617 $ $ With Seat t ack Hardware Withut Seat t ack Hdw 067ZE43 $ ZE21 $ ZE44 $ ZE24 $ ZE45 $ ZE26 $ ZE46 $ ZE29 $ ZE47 $ ZE22 067ZE36 067ZE37 $ ZE49 $ ZE39 $ ZE48 $ ZE35 067ZE55 $ ZE40 067ZE62 $ ZE63 $ ZE64 $ ZE31 AK FOAM OPTIONS ** Transit Apprved Fam nstructin Middle Thickness 067YV01 Single Layer Fam N/ HR Fam - 50 r YV02 2 Layer Fam N/ 067ZA01 1/2" $20 067ZA05 2 1/2" $ YV03 3 Layer Fam N/ 067ZA02 1" $40 067ZA06 3" $ YV04 Omit ack Fam N/ 067ZA03 1 1/2" $60 067ZA07 3 1/2" $140 Fam Layer Density 067ZA04 2" $80 Tp Middle ttm T Fam - XS r S HR Fam ZA26 1/2" $20 067ZA29 2" $80 HR Fam ZA27 1" $40 067ZA30 2 1/2" $100 T Fam-XS (Yellw) 067ZA28 1 1/2" $60 067ZA31 3" $120 T Fam-S (Pink) Sunmate Sft, Medium, MediumSft, r Firm Sunmate-Sft 067ZA09 1/2" $45 067ZA13 2 1/2" $225 Sunmate-Medium 067ZA10 1" $90 067ZA14 3" $270 Sunmate-MediumSft 067ZA11 1 1/2" $ ZA15 3 1/2" $315 Sunmate-Firm 067ZA12 2" $180 ack Fam Optins 067ZA17 1/2" $ ZA20 2" $ U01 Incntinent Wrap N/ 067ZA18 1" $ ZA21 2 1/2" $ ZA19 1 1/2" $ ZA22 3" $900 Tp Thickness Standard Snaptite Universal ttm Thickness Adjustable Wide J3 ack Style Quickie TS Snap 2 Pin Adjustable J&L HR Fam - 50 r 70 HR Fam - 50 r YY01 1/2" $20 067YY05 2 1/2" $ Z01 1/2" $20 067Z05 2 1/2" $ YY02 1" $40 067YY06 3" $ Z02 1" $40 067Z06 3" $ YY03 1 1/2" $60 067YY07 3 1/2" $ Z03 1 1/2" $60 067Z07 3 1/2" $ YY04 2" $80 067Z04 2" $80 T Fam - XS r S T Fam - XS r S 067YY26 1/2" $20 067YY29 2" $80 067Z26 1/2" $20 067Z29 2" $80 067YY27 1" $40 067YY30 2 1/2" $ Z27 1" $40 067Z30 2 1/2" $ YY28 1 1/2" $60 067YY31 3" $ Z28 1 1/2" $60 067Z31 3" $120 Sunmate Sft, Medium, MediumSft, r Firm Sunmate Sft, Medium, MediumSft, r Firm 067YY09 1/2" $45 067YY13 2 1/2" $ Z09 1/2" $45 067Z13 2 1/2" $ YY10 1" $90 067YY14 3" $ Z10 1" $90 067Z14 3" $ YY11 1 1/2" $ YY15 3 1/2" $ Z11 1 1/2" $ Z15 3 1/2" $ YY12 2" $ Z12 2" $ YY17 1/2" $ YY20 2" $ Z17 1/2" $ Z20 2" $ YY18 1" $ YY21 2 1/2" $ Z18 1" $ Z21 2 1/2" $ YY19 1 1/2" $ YY22 3" $ Z19 1 1/2" $ Z22 3" $900 ustmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. pyright 2015 Sunrise Medical (US) LL. JAY SURE FIT / AES Lite, MK REV. Page 3
4 SEAT - E2609 Seat Style 067YH01 Standard Planar $ YH06 Omit 067YH08 Omit Plywd Seat Style Optin * Fam Thickness Only SEAT MODIFIATION Nte: Mdificatins retail is added t the price f the Planar ack 067YI02 Asymmetrical Seat $ YH04 ntur Seat $ * Fam Thickness Only * Fam Thickness Only D Lng Side: R L E Nte: If adding a Medial Thigh add at least 1.5" past center line fr prper munting. 067YH03 Anti-Thrust Mdificatin $ * Fam Thickness Only D ver Optins ver Optins Misc. 067YJ01 Standard Zipper Access ver N/ NEW OMIT VELRO 067YJ03 Remvable Zipper Access ver $ IU01 Add Velcr Strips (ttm f the ushin) $ IU02 Add Velcr Strips (Tp f the ushin) $25.00 Grwth Ntches (W" X D") Type f Velcr 067GO01 2" x 2" Grwth Tail Ntch N/ 067IV01 Hk 067GO02 2" x 3" Grwth Tail Ntch N/ 067IV02 Lp (Standard) Seat Misc 067YI05 Tw Piece ushin & ase $ SEAT UPHOLSTERY Nte: Visit fr a full list f clrs available. ntact Surface Nn-ntact Surface 067YR22 Rubatex - lack 067YR31 Rubatex - lack 067YR01 Naugahyde/Vinyl 067YR32 Naugahyde/Vinyl lr: lr: 067YR29 Dartex - lack 067YR48 Dartex - lack 067YR30 Reverse Dartex - lack 067YR49 Reverse Dartex - lack ustmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. pyright 2015 Sunrise Medical (US) LL. JAY SURE FIT / AES Lite, MK REV. Page 4
5 SEAT HARDWARE - E2609 Seat Hardware With Seat t ack Hardware Withut Seat t ack Hdw Snaptite 1" STD** 067ZE50 $ ZE11 $ Snaptite 1 1/2" Drp 067ZE51 $ ZE14 $ Snaptite 3" Drp 067ZE52 $ ZE16 $ Quickie TS Snap 2 pin 067ZE53 $ ZE13 $ Quickie TS Snap 4 pin** 067ZE54 $ ZE22 $ Flush Hks 067ZE65 $ ZE66 Universal Transit Standard** 067ZE56 $ ZE41 $ Universal Transit Space Saver** 067ZE57 $ ZE42 $ Adjustable J&L (J-2 Hle & L-6 Hle) Std 067ZE55 $ ZE40 $ Adjustable J&L (Std) w/ Shurlck Rel/Fixed 067ZE62 $ Adjustable J&L (Std) w/ Shurlck Release 067ZE63 $ ZE64 $ Omit Seat Hardware 067ZE17 Nte: Space saver hardware will be used fr any seat under 14" Wide Standard Snaptite ** Transit Apprved Adjustable J&L Universal Hardware Quickie TS Snap 2 Pin Space Saver SEAT FOAM OPTIONS Fam nstructin Middle Thickness 067YK01 Single Layer Fam N/ HR Fam - 50 r YK02 2 Layer Fam N/ 067YO01 1/2" $20 067YO05 2 1/2" $ YK03 3 Layer Fam N/ 067YO02 1" $40 067YO06 3" $ YK04 Omit Seat Fam N/ 067YO03 1 1/2" $60 067YO07 3 1/2" $140 Fam Layer Density 067YO04 2" $80 Tp Middle ttm T Fam - XS r S HR Fam YO26 1/2" $20 067YO29 2" $80 HR Fam YO27 1" $40 067YO30 2 1/2" $100 T Fam-XS (Yellw) 067YO28 1 1/2" $60 067YO31 3" $120 T Fam-S (Pink) Sunmate Sft, Medium, MediumSft, r Firm Sunmate-Sft 067YO09 1/2" $45 067YO13 2 1/2" $225 Sunmate-Medium 067YO10 1" $90 067YO14 3" $270 Sunmate-MediumSft 067YO11 1 1/2" $ YO15 3 1/2" $315 Sunmate-Firm 067YO12 2" $180 Seat Fam Optins 067YO17 1/2" $ YO20 2" $ U01 Incntinent Wrap N/ 067YO18 1" $ YO21 2 1/2" $ YO19 1 1/2" $ YO22 3" $900 Tp Thickness ttm Thickness HR Fam - 50 r 70 HR Fam - 50 r YM01 1/2" $20 067YM05 2 1/2" $ YQ01 1/2" $20 067YQ05 2 1/2" $ YM02 1" $40 067YM06 3" $ YQ02 1" $40 067YQ06 3" $ YM03 1 1/2" $60 067YM07 3 1/2" $ YQ03 1 1/2" $60 067YQ07 3 1/2" $ YM04 2" $80 067YQ04 2" $80 T Fam - XS r S T Fam - XS r S 067YM26 1/2" $20 067YM29 2" $80 067YQ26 1/2" $20 067YQ29 2" $80 067YM27 1" $40 067YM30 2 1/2" $ YQ27 1" $40 067YQ30 2 1/2" $ YM28 1 1/2" $60 067YM31 3" $ YQ28 1 1/2" $60 067YQ31 3" $120 Sunmate Sft, Medium, MediumSft, r Firm Sunmate Sft, Medium, MediumSft, r Firm 067YM09 1/2" $45 067YM13 2 1/2" $ YQ09 1/2" $45 067YQ13 2 1/2" $ YM10 1" $90 067YM14 3" $ YQ10 1" $90 067YQ14 3" $ YM11 1 1/2" $ YM15 3 1/2" $ YQ11 1 1/2" $ YQ15 3 1/2" $ YM12 2" $ YQ12 2" $ YM17 1/2" $ YM20 2" $ YQ17 1/2" $ YQ20 2" $ YM18 1" $ YM21 2 1/2" $ YQ18 1" $ YQ21 2 1/2" $ YM19 1 1/2" $ YM22 3" $ YQ19 1 1/2" $ YQ22 3" $900 ustmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. pyright 2015 Sunrise Medical (US) LL. JAY SURE FIT / AES Lite, MK REV. Page 5
6 HEAD SUPPORT - E0955 Pad Style 067ZH14 8" Plush $ ZH15 10" Plush $ ZH16 14" Plush $ ZH17 19" Plush $ ZH18 Standard Adjust-a-Plush 067ZH19 Narrw Adjust-a-Plush 067ZH20 Small ntur radle $ ZH21 Med ntur radle $ ZH22 Large ntur radle $ ZH24 Omit N/ Pad ver 067Y024 Lycra N/ 067Y025 Reverse Dartex N/ 067ZK08 067ZK09 067ZK10 067ZK11 067ZK12 067JD01 067JD02 067JE01 Munting System - E1028 ONYX Detachable racket ONYX Detachable w/ffset vertical bar AXYS Detachable racket LINX Detachable racket ORA Detachable racket Munting Plate Universal Munting Plate Swing Away Plate Dynamic Frehead Strap Dynamic Frehead Strap Adult $ $ $ $ $ $85.00 $55.00 $ LATERAL THORAI SUPPORTS - E0956 racket Style - Pair Additinal Hardware/Optins 067ZS01 Fixed $ ZY05 Quick Adj(sumr/wntr-pr) $ ZS02 Swing Away E1028 $ ZY10 Hdw racket vers $ ZS03 Omit racket Offset Pad Size - Sld as Pair 067ZT04 Flush N/ 067ZV01 3"H x 4"L $ ZT05 1" Offset N/ 067ZV05 4"H x 5"L $ ZT06 2" Offset N/ 067ZV06 4"H x 6"L $ ZV13 5"H x 6"L $ racket Prfile ustm 067JG01 Standard - 1" N/ H x L Thick* $ JG02 Medium - 2" N/ * Fam thickness nly 067JG03 High - 3" N/ 067ZU01 067ZU02 067ZU08 067ZY10 067ZY06 067ZY07 067ZY08 067ZY09 Pad Style Flat D urved D Taper Style Pad Spacers 1/4" Per Side 1/2" Per Side 1" Per Side 1 1/2" Per Side 2" Per Side $15.00 $30.00 $60.00 $90.00 $ LATERAL PELVI SUPPORTS - E0956 racket Style - Pair Pad Size - Sld as Pair 067XO01 Fixed $ XR01 3"H x 4"L $ XO03 Remvable E1028 $ XR05 4"H x 5"L $ XO05 Omit 067XR06 4"H x 6"L $ racket Offset 067XR11 5"H x 6"L $ X01 Flush N/ ustm 067X02 067X03 1" Offset 2" Offset N/ N/ H x L * Fam thickness nly Thick* $ XR10 ustm ntur t Seat $ racket Prfile 067JG04 067JG05 067JG06 Standard - 1" Medium - 2" High - 3" N/ N/ N/ Spacers 067XS09 1/4" Per Side $ XS05 1/2" Per Side $ XS06 1" Per Side $ XS07 1 1/2" Per Side $ XS08 2" Per Side $ LATERAL THIGH/KNEE SUPPORTS - E0956 racket Style - Pair racket Prfile Pad Size - Pair 067XJ01 Fixed $ JG07 Standard - 1" N/ 067XM01 3"H x 4"L $ XJ03 Remvable E1028 $ JG08 Medium - 2" N/ 067XM05 4"H x 5"L $ XJ05 Frm Mnt Flip Dwn-(Lng) $ JG09 High - 3" N/ 067XM06 4"H x 6"L $ XJ06 Omit racket Offset Nt Available with Flip Dwn Style Spacers 067XM12 067XM13 5"H x 6"L 3" Knee Pad* $ $ XK05 Flush N/ 067XN09 1/4" Per Side $ XM14 4" Knee Pad* $ XK06 1" Offset N/ 067XN05 1/2" Per Side $30.00 ustm 067XK07 2" Offset N/ 067XN06 1" Per Side $60.00 H x L Thick** $ Nt Available with Flip Dwn Style 067XN07 1 1/2" Per Side $90.00 * Available with Flip Dwn Style Only 067XN08 2" Per Side $ * *Fam thickness nly Nt Available with Flip Dwn Style ustmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. pyright 2015 Sunrise Medical (US) LL. JAY SURE FIT / AES Lite, MK REV. Page 6
7 MEDIAL THIGH ADUTOR - E KH8 067KH10 067KH11 067KH9 067KH10 racket Style Push tn Flip Dwn E1028 Pull Away AES Style E1028 Omit Pad Style Oval Wedge $ $ N/ N/ 067KH4 067KH5 067KH6 067KH7 Pad Size Sml (3x4x3) Med (4.5x5x3) Lrg (5x5x4) ustm-see Diagram $ ustm Oval Sizes ustm Wedge Sizes A. Height A. Height. Length. Length. Width. Width Frnt D. Width Rear MISELLANEOUS Anterir Pelvic elts - E0978 JAY Standard 2 Pint elt - Push uttn 1" 067ZZ10 N Pad $ ZZ11 4.5" Pad $ ZZ12 5.5" Pad $ ZZ13 7.5" Pad $40.00 JAY Standard 2 Pint elt - Push uttn 1 1/2" 067ZZ14 N Pad $ ZZ15 7.5" Pad $ ZZ16 9.5" Pad $40.00 JAY Medial 4 Pint elt - Push uttn 1 1/2" 067ZZ17 4.5" Pad $ ZZ18 5.5" Pad $40.00 JAY V-ntur Pelvic 4 Pint elt - Push uttn Varies 067WV01 Small Pad - 1" Push uttn $ WV02 Medium Pad - 1 1/2" Push uttn $ WV03 Large Pad - 2" Push uttn $ Anterir Trunk Supprts - E Style 067JJ01 JAY lassic - Structured $ JJ02 JAY lassic - Dynamic $ JJ03 JAY ntur - Structured $ JJ04 JAY ntur - Dynamic $ JJ16 JAY ack Pack Style Structured $ JJ17 JAY ack Pack Style Dynamic $ a. lassic and ntur Size 067JJ05 Early Interventin 067JJ06 X-Small 067JJ07 Small 067JJ08 Medium 067JJ09 Large 067JJ10 X-Large 2b. ack Pack Size 067A481 12" 067A482 18" 3. Strap Guides (Optinal) 067JJ11 Strap Guide $ Style 2. Size She Hlders (E0951/E0952) Pair 067XU05 Padded $ XU06 Tendn Relief $ XU01 Small 067XU02 Medium 067XU03 Large 067XU04 X-Large 1. Style 2. Size Ankle Psitiners 067F320 Ankle Psitiner (Ft & Ankle) $ F321 Flexi Feet $ IL01 X-Small - N/A w/ Ankle Psitiner 067IL02 Small 067IL03 Medium 067IL04 Large 067IL05 X-Large - N/A w/ Flexi Feet ustmer Service: Fax: rders@sunmed.cm Specificatins are subject t change withut ntice. pyright 2015 Sunrise Medical (US) LL. JAY SURE FIT / AES Lite, MK REV. Page 7
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