Freedom Designs, Inc. Easy Form

Transcription

1 . Easy Form ustomer Information ate: Purchase Order #: ealer / cct. #: Ship to Street: Ship to ity: Ship to State: Freedom Install Program Purchase Order #: of frame for install Freedom Install Program does not include power wheelchairs. Wheelchair Specifications Model: Width: epth: Ship to Zip ode: Office / Mobile #: Office Fax #: ddress: Quote to: Fax uyer: Marked For: Upholstery, Monograms, and esigns Total system covered in one upholstery? Yes or No ontact Surface Non-contact Surface Monogram Name Font - Script or lock - Thread olor esign Seating Specifications ack Height: Lateral Height: Lateral Width: Finished imensions Standard cut is oltaron with foam rolled over edge. I Hip Width (rear): E Set Up Seat epth: F Hip Width (front): G E + 3 for Growth: H Seat Width: F I ack Width: Important Note: To ensure quote accuracy, seat and back width, depth and height dimensions must be provided. Seats and backs over 18 in width, depth or height are subject to oversize charges. G E H 2241 N. Madera Rd. Simi Valley, Phone Fax SOMT Rev Page 1 of 9

2 Easy Form - Seat Step 1. hoose Hardware for Planar / Flat Seat Note: Price includes 1/2 wood, 1-1/2 4# foam and choice of upholstery. EE1 EE1-No Hardware EZ Lite 1 EZ Lite 1-EXT EXT Two Knobs/Hinge (transport approved) Two Knobs/Hinge - No Hardware Two EZ Lite/Hinge Two EZ Lite/Hinge (transport approved) Seat Insert Seat Inserts w/t-nuts J/L Quick Release (transport approved) Four Knobs (transport approved) Four EZ Lite Four EZ Lite Extended (transport approved) Step 2. hoose Modifications to Planar / Flat Seat MO-1K nti-thrust Seat dd $210 MO-1Y ontour Seat dd $326 $646 $237 $471 $471 $172 $225 $602 $698 $471 $471 Height of anti-thrust shelf is 1 = 3rd of set up seat up depth (see page1) Leg trough depth is 1 Height of anti-thrust is 1 = Half of set up seat depth (see page1) MO-1R symmetrical - Long Right dd $ 88 MO-1L symmetrical-long Left dd $ 88 MO-1G MO-1I MO-1L MO-1O MO-1P MO-1 MO-1EE MO-1FF MO-1GG MO-1ROHO Seat ushion Separate From Wood Incontinent Liner Grid Seat Modification Notch For ack Posts Hook & Loop Strips Modular ontour Seat Foam Full Width / Wood etween Removable Incontinent Slip over Track Mount Hardware - Long ual Tracks Freedom Seat ROHO Insert (see pg. 8 to specify order) Step 3. hoose Foam 1.5 Std 4# Foam Only OR ustom/omit Standard (see chart below) dd $105 dd $ 30 dd $333 n/c dd $ 47/pr dd $432 dd $164 dd $204 dd $ 53/pr dd $765 ase layer to be: Middle layer to be: Top layer to be: Seat Foam hart 3# Foam $ 45 per 1 Firm Sunmate $ 82 per 1 Pudgee $209 per 1 4# Foam $ 45 per 1 X-Soft T-Foam $ 89 per 1 Waffle $269 per.5 5# Foam $ 47 per 1 Soft T-Foam $ 89 per 1 Waffle (over 18x16) $540 per.5 Soft Sunmate $ 82 per 1 Medium T-Foam $ 89 per 1 Free Float $338 per.5 Med. Sunmate $ 82 per 1 Firm T-foam $ 89 per 1 Free Float (over 18x16) $674 per N. Madera Rd. Simi Valley, Phone Fax SOSS Rev Page 2 of 9

3 Easy Form - ack Step 1. hoose Hardware for Planar / Flat Seat Note: Price includes 1/2 wood, 1 4# foam and choice of upholstery. EE2 EE2-No Hardware Easy lamp2 Fast lamp2 Rotate Easy lamp Two Knobs/Hinge (transport approved) Two Knobs/Hinge - No Hardware Two Easy lamps/hinge (transport approved) Two Fast lamps (transport approved) Two Rotate lamps/hinge (transport approved) Four Knobs (transport approved) Four Easy lamps (transport approved) Four Rotate lamps (transport approved) $646 $238 $549 $443 $462 $762 $639 $462 Step 2. hoose Modifications to Planar / Flat ack MO-2I urved Wood dd $134 MO-2I urved Foam dd $115 MO-2H I-MO dd $128 MO-2J T-MO dd $128 E E E MO-2L iangular dd $303 MO-2 djust. Lumbar dd $299 Split at from bottom Start at from bottom MO - 2K MO - 2ROHO ack MO - 2S MO - 2S1 MO - 2GG MO - 2JJ Grid ack Freedom ack ROHO Insert (see pg.9 to specify order) Foam-In-Place X Soft X Medium Foam-In-Place (chemicals only) X Soift X Medium Ergo djustable Track Mount Hardware - Long ual Tracks dd $333 dd $765 dd $259 dd $242 dd $422 dd $ 58/pr Step 3. hoose Foam 1 Std 4# Foam Only OR ustom/omit Standard (see chart below) ase layer to be: Middle layer to be: Top layer to be: ack Foam hart 3# Foam $ 45 per 1 Firm Sunmate $105 per 1 Pudgee $226 per 1 4# Foam $ 45 per 1 X-Soft T-Foam $113 per 1 Waffle $269 per.5 5# Foam $ 62 per 1 Soft T-Foam $113 per 1 Waffle (over 18x16) $540 per.5 Soft Sunmate $105 per 1 Medium T-Foam $113 per 1 Free Float $338 per.5 Med. Sunmate $105 per 1 Firm T-foam $113 per 1 Free Float (over 18x16) $674 per N. Madera Rd. Simi Valley, Phone Fax SOSS Rev Page 3 of 9

4 Easy Form - ccessories Medial Thigh - bductor/pommel EE3-2 Flip own bductor $444 Wedge Or Oval MO-3E bductor Pad Only $170 MO-3F Extension racket/bductor $ 28 EE3M nti-thrust Pelvic Harness $247 S M L XL or Hip Width Hip Guides EE4/ Fixed - Flush/Offset $237/pair EE4 Quick Release Hip Guide $474/pair MO-4 ontour for nti-thrust $ 90/pair MO-4 Extension racket/dd $ 42/ea = 4 high or = Set up seat depth or Flush 1 2 Mounted at: Hip or Knee Standard Sizes Small 3L x 3H x 3-2 Taper Medium 4L x 3H x 3-2 Taper Large 5L x 4H x 4-2 Taper X-Large 6L x 5H x 5-3 Taper Trunk Supports EE5/ Fixed - Flush/Offset $237/pair Tracks EE5E LIft Swing way $474/pair 3 Single EE5I Tracks $ 52/pair 4L x 3H 5 Single 5L x 4H 7 Single EE5J Fixed Swing way Summer Winter $402/pair 6L x 5H 9 Single EE5K Lever Swing way $633/pair 11 Single Trunk Supports EE5P Lever Swing way Summer Winter $532/pair 9 ouble Std. (1 thick) OR Thin (.5 thick) Flat OR urved 11 ouble EE5Q Swing way Summer Winter $669/pair EE5W NEW Push utton S/ $474/pair Flush 1 2 MO-5F Procetive overing Over Hardware $ 54/pair Headrest Hardware 7700 Vertical and Horixontal djustment - Fixed Removable $ Flip own - Not Removable $ Rock and Roll Removable $ Rock and Roll Flip own - Not Removable $ NEW djust-exe Multi-Position Removable $ daptapllate - Universal Plate - Freedom esigns and Other Manufactures $ 63 77Platemate Universal Plate for all Headrests - Whitmyer, Otto ock, Stealth $ 43 Headrest Pads 7755 Extension Pad W x H $ Piect Hinged Small 4W x 4H Medium 4W x 5H Large 5W x 5H $ hubbie Small 10W x 4H Medium 12W x 5H Large 13.5W x 4.5H $ Low Profile Small 8.5W x 3.5H Medium 9W x 4H Large 3W x 4H $ Skinny Small 8W x 4.5H Medium 10W x 4.5H Large 12W x 4.5H $188 elts S-3331 Squeeze Release, 2 pt., enter Pull XS S M L XL $ 68 S-3332 Metal Push utton, 2 pt., enter Pull XS S M L XL $ 90 S-3334 EZ-Release, 2 pt., enter Pull XS S M L XL $ 90 S-3362 EZ-Release, 4 pt., enter Pull XS S M L XL $ N. Madera Rd. Simi Valley, Phone Fax SOSS Rev Page 4 of 9

5 nkle Supports Freedom esigns, Inc Easy Form - Trays and Foot oxes EE9- High Top, uckle, ynamic XS S M L $111 EE9F- 3 Point High Tops XS S M L $169 nkle ircumference= (5 1/2-8 1/2 ) (7 1/2-10 1/2 ) (9 1/2-12 1/2 ) (11 1/2-14 1/2 ) Shoe Holders EE9 Shoe Holders - Velcro S SM M ML L XL $166 EE9 Shoe Holders - uckle S SM M ML L XL $166 EE9G Shoe Holders - ombo S SM M ML L XL $166 Shoe Sizing= (5 ) (5.75 ) (6.5 ) (7.25 ) (8 ) (10 ) MO-9G Foot Plate Pads - Pair W x $161 Foot oxes Leg radles $ Foot ox $515 Hanger Mount Footplate/Footboard Mount W Fits between hangers H Tray What is the width of the frame? Lexan Tray w/velcro $ Lexan Tray w/hannel rackets & Ribs $ Lexan Tray w/djustable Hardware & Ribs $ Lexan Tray Nor Hardware $ EZ-LIte Tray $ EZ-Lite Tray w/ribs $ /4: Laxan Tray w/hook & Loop $106 Tray Sizes Size escription X-Small wide chair, Tray dimensions 21 wide x 18 deep, body cut out 10 w x 7 deep Small wide chair, Tray dimensions 21 wide x 18 deep, body cut out 12 w x 7 deep Medium wide chair, Tray dimensions 24 wide x 22 deep, body cut out 14 w x 9 deep Large wide chair, Tray dimensions 26 wide x 24 deep, body cut out 16 w x10 deep X-Large wide chair, Tray dimensions 28 wide x 14 deep, body cut out 18 w x10 deep 2241 N. Madera Rd. Simi Valley, Phone Fax SOSS Rev Page 5 of 9

6 Easy Form - nterior hest Supports nterior hest Supports MO-6-1 Strap Riser $53/pr. EE6R $164 EE6S $164 EE6U $164 EE6V $164 Size XX Small XSmall Small Medium Large XLarge EE6X $165 hest Support Length of Pad XXS XS S M L XL EE6R EE6S EE6U N/ EE6V N/ EE6X N/ N/ N/ 2241 N. Madera Rd. Simi Valley, Phone Fax SOSS Rev Page 6 of 9

7 Easy Form - Select nterior hest Supports Freedom Select nterior Trunk Supports Select Standard Select Narrow Select Standard Zipper Select Narrow Zipper Freedom Select Support Order Part Number Freedom Select Support imensions Price E F G SFI-6SNZ-S Select Standard Small $133 SFI-6SNZ-M Select Standard Medium $133 SFI-6SNZ-L Select Standard Large $143 SFI-6SNZ-XL Select Standard Extra Large $143 SFI-6NNZ-M Select Narrow Medium $133 SFI-6NNZ-L Select Narrow Large $138 SFI-6NNZ-XL Select Narrow Extra Large $143 SFI-6SZ-S Select Standard Zipper Small $138 SFI-6SZ-M Select Standard Zipper Medium $138 SFI-6SZ-L Select Standard Zipper Large $143 SFI-6SZ-XL Select Standard Zipper Extra Large $148 SFI-6NZ-M Select Narrow Zipper Medium $138 SFI-6NZ-L Select Narrow Zipper Large $143 SFI-6NZ-XL Select Narrow Zipper Extra Large $ N. Madera Rd. Simi Valley, Phone Fax SOSS Rev Page 7 of 9

8 PO# Marked for: ell Size eleted ells ase Intact X MO-1ROHO SET Freedom Seat ROHO Insert $ Note: Retail pricing includes any combination of specification option. FRONT OF INSERT OLUMNS INHES ELLS E F G H I J K L ut Out ells & ase Valve Hose Location orner & ell Height V1 V2 V3 V4 Select Seat hoice Standard R O W S INHES RE FROM SE EGE TO EGE OF INSERT symmetrical Left symmetrical Right 1. Start diagram at cell 1 which represents front left of cushion from client s seated position. 2. Specify ell Height (1, 2. 3 or 4 ) by placing a number in each cell box. 3. Specify request to elete ells with ase Intact by typing an X in those cell boxes. 4. Specify request to ut Out ells & ase by typing a in those cell boxes. 5. Specify Valve Hose Location orner & ell Height by typing V1, V2, V3 or V4 in that corner box. Note: For multiple valve or custom valve locations and custom air chamber divisions call Freedom esigns ustomer Service for assistance at Other PLESE LLOW 3-4 WEEKS FOR ELIVERY 2241 N. Madera Rd. Simi Valley, Phone Fax SOSS Rev Page 8 of 9

9 PO# Marked for: ell Size eleted ells ase Intact X MO-2ROHO K Freedom ack ROHO Insert $ Note: Retail pricing includes any combination of specification option. INHES ELLS TOP OF INSERT OLUMNS E F G H I J K L ut Out ells & ase Valve Hose Location orner & ell Height V1 V2 V R O W S Select ack hoice Standard I ack T ack INHES RE FROM SE EGE TO EGE OF INSERT 1. Start diagram at cell 1 which represents top right of back from client s seated position. 2. Specify ell Height (1, 2. or 3 ) by placing a number in each cell box. 3. Specify request to eleted ells with ase Intact by typing an X in those cell boxes. 4. Specify request to ut Out ells & ase by typing a in those cell boxes. 5. Specify Valve Hose Location orner & ell Height by typing V1, V2, or V3 in that corner box. Note: For multiple valve or custom valve locations and custom air chamber divisions call Freedom esigns ustomer Service for assistance at PLESE LLOW 3-4 WEEKS FOR ELIVERY 2241 N. Madera Rd. Simi Valley, Phone Fax SOSS Rev Page 9 of 9