ORDER FORM ZITZI SHARKY PRO

Transcription

1 ORDER FORM ZITZI SHRKY PRO Date Customer illing/delivery address Consultant Tryed out by User Prescriber Try-out time. Hour Traveling time Hour/dist. Order Custom made lready delivered Offer Proforma Days 1 Seat part Seat part includes: Complete seat with adjustable seat parts (not flat seat) Gas spring with Flex (gives flexible function to the back part) Hip belt DWSR Cushion (not flat seat) Seat depth Sharky Pro size 1 (without back) Sharky Pro size 2 (without back) cm cm Sharky Pro flat seat size 1* (without back) Sharky Pro flat seat size 2* (without back) and must be combined with plane plate , eller Plane plate 350x375 mm** Plane plate 375x400 mm** Plane plate 400x425 mm** The plane plate can be rotated to get the measurements reversed (375x350, 400x375, 425x400). 2 ack ack includes: Lumbar support (integrated) Cushions Safety strap llen wrench 4 mm Height ack size 1, cpl ack, re-inforced size 1, cpl ack size 2, cpl ack, re-inforced size 2, cpl. 52 cm 52 cm 60 cm 60 cm Sacrum support Fits all Sharky backs Sacrum support

2 3 Lateral support Lateral support includes: Mounting kit Cushion Chest width/depth Lateral support, fixed, size 3 - Delfi Pro Lateral support, fixed, size 1 - Sharky Pro Lateral support, fixed, size 2 - Sharky Pro Lateral support, fixed/reinforced, size Lateral support, fixed/reinforced, size Lateral support, swing away, size Lateral support, enclosing, swing away cm/17,5 cm cm/21 cm cm/25 cm cm/21 cm cm/25 cm cm/21 cm cm/21 26 cm Lateral support 4 Cushion If no choice is made Fabric Grey/lack is included as standard. ll cushions are made of fabric that is fire tested and approved according to EN Grey/lack (std.) * lcantara lack ** * Cushions for lateral support and leg parts are in black fabric. ** Cushions for lateral support, leg parts and headrest are in black fabric. 5 Head support Headrest includes: Headrest plate Cushion Stay racket Sharky Pro Standard Headrest size 1 long, cpl Headrest size 2, cpl. Sharky Pro Standard Pro Serie Vuxen Headrest size 2 long, cpl. ccessories Sharky Pro Standard ctive forehead strap, dult, Pro Serie ctive forehead strap, Junior, Pro Serie Must be completed with Pro Serie Plush Pro Serie Mini Stay, ctive forehead strap, Zitzi Headrest bracket I2I Std Flexible MH headrest, Zitzi Foldable MH Zitzi Long Headrest size 1 long Headrest size 2 Headrest size 2 long 280 x 160 mm 240 x 190 mm 280 x 210 mm

3 Head ctive Head ctive kit 2 - Head ctive ccessories Head ctive MH Head ctive (for mounting on Zitzi) Extension 15cm - Head ctive (incl. in ) Extension 15 cm Heads First/Pro Serie lack ear, dult, Heads First lack ear extended, dult, Heads First Samtliga Pro-huvudstöd måste kompletteras med adapterstag och huvudstödsfäste Pro dult Pro Mini size M (25,5x12 cm) Pro Mini size L (32,5x16 cm) Pro Plush Pro Plush Pro Plush adjustable Pro Plush adjustable Pro Heads up size M, long Pro Heads up size M, short Pro Serie Mini Pro Serie Pro Serie Junior Pro Serie Plush ccessories Pro Serie Vertical stay to 15x15 mm removable bracket Headrest bracket djustable headrest bracket (repl ) ctive forehead strap, dult, Pro Serie ctive forehead strap, Junior, Pro Serie Mounting bracket, ctive forehead strap/bow, Plush Flexible MH headrest, Zitzi Foldable MH Zitzi * and must be combined with Not necessary for Pro Serie Plush djustable Small short 14 Small long 18 Small 9 Pro Heads Up

4 6 Positioning support Lower mounting bracket (art. nr ) included as standard Mounting brackets Upper mounting brackets, long Lower mounting bracket (mounted in the seating base) ll harnesses are delivered without mounting brackets. Complete with upper and lower mounting brackets ( and ). Chest harnesses Pro Exclusive Sternum support size M Sternum support size L C H-Strap M (cm) 11,5 39,5 Sternum support M (cm) C 17 L (cm) 11,5 46 L (cm) H-strap size M H-strap size L Chest belt Soft, cpl. racelet Sternum support H-strap 3781 racelet Exclusive stl. L racelets are delivered in pair racelet Soft stl. L Hip belts nti-rotational belt size M, Car lock nti-rotational belt size M, DWSR40 Hip belt DWSR is included as standard nti-rotational belt size L, Car lock nti-rotational belt size L, DWSR nti-rotational belt size M, 340 (reinforced) Hip belt 742, repl. std. Hip belt nti-rotational belt Pelvis support/hip support Pelvis support, cpl Hip support size 3 Left/Right Zitzi Pelvis support Hip support

5 Foot-/ankle holder 3772 nkle holder Exclusive size M (velcro) 3773 nkle holder Exclusive size L (velcro) nkle holder, leg strap and foot strap delivered in pair. Mounted on the footplate. nkle holders nkle holder Soft size M (velcro) nkle holder Soft size L (velcro) nkle holder Pro size M (buckles) nkle holder Pro size L (buckles) Exclusive Soft Pro Leg straps Soft size Leg straps Soft size Foot strap 25 mm size S (520 mm long) Foot strap 25 mm size L (700 mm long) Measurement around ankle size M mm size L mm Foot strap 7 rmrest rmrest and upper arm support delivered in pair. rmstöd rmrest size 1 (seat base) rmrest fixed size 1 (back) rmrest foldable size 1 (back) Upper arm support x Size x 75 mm ccessories rmrest Cover armrest plate size 4 - Zitzi. Fits , and Cover armrest plate size 5 - Zitzi. Fits , and Table Table size 3 - Delfi Pro Table size 1 - Sharky Pro Table size 2 - Sharky Pro Table Table turn-up Table reinforced Table turn-up size 3 - Delfi Pro Table turn-up size 1 - Sharky Pro Table turn-up size 2 - Sharky Pro Table, reinforced mount.brackets, size 3 - Delfi Pro Select table after chest width! Table Chest width Size 3 - Delfi Pro < 30 cm Size 1 - Sharky Pro < 34,5 cm Size 2 - Sharky Pro < 39 cm Table, reinforced mount. brackets, size 1 - Sharky Pro Table, reinforced mount. brackets, size 2 - Sharky Pro

6 9 Footrest/calf support Footrest Footrest divided size 1 Size 1 fits Sharky Pro size 1 = size 3 plate Size 2 fits Sharky Pro size 2 = size 4 plate Footrest divided size Footrest divided, turn-up, size Footrest divided, turn-up, size Footrest divided, ball joint, size Footrest divided, ball joint, size Footrest size Footrest size 2 ccessories Footrest Footrest divided/turn-up/ball-joint Footrest Footrest, high edge size 3 (divided footplate). Fits Footrest, high edge size 4 (divided footplate). Fits Cushion footrest size 3. Fits Footrest size 1 (all choices) Cushion footrest size 4. Fits Footrest size2 (all choices). Footrest high edge must be combined with footrest. Calf support Calf support size 1 (120x145 mm) 2 stay Calf support size 2 (150x155 mm) 2 stay Calf support size 3 (225x150 mm) 2 stay ccessories Calf support Cushion calf support size 1. Fits Cushion calf support size 2. Fits Cushion calf support size 3. Fits Calf support 10 Other accessories Cushion/cover Cover inkoncontinent seat part size 1, lack Cover inkoncontinent seat part size 2, lack Cover inkoncontinent back size 1, lack Cover inkoncontinent back size 2, lack Cushion seat part RR size 1, Grey Cushion seat part RR size 2, Grey Cushion seat part T-foam size 1, Grey Cushion seat part T-foam size 2, Grey Mounting system dapter system Pro dapter plate Pro (mounted on the chassi) Mounting plate Pro (mounted on the seat) ( )

7 Thermal bag Thermal bag without backpart size M Thermal bag without backpart size L Thermal bag without backpart size XL Other accessories Driving bow Termopåse Sufflett Körbåge Sun cover DP/SP - Zitzi racket sun cover DP/SP kpl. 11 Spare parts Headrest bracket Cover Headrest size 1 long, lack Cover Headrest size 2, lack Cover Headrest size 2 long, lack Reinforcement tube size 1-2 (back) Reinforcement kit stl Reinforcement kit stl Cushion ack part size 1, Grey (std.) Cushion ack part size 2, Grey (std.) Cushion lcantara ack part size 1, lack Cushion lcantara ack part size 2, lack ack profile size ack profile size ack part plastic size ack part plastic size ack spacer, carriage bolt size ack spacer, carriage bolt size Cushion Lateral support size 3, lack - Delfi Pro Cushion Lateral support size 1, lack - Sharky Pro Cushion Lateral support size2, lack - Sharky Pro Lateral support size 1, left Lateral support size 1, right Lateral support size 2, left Lateral support size 2, right Reinforcement plate, Lateral Support size Reinforcement plate, Lateral Support size racket Lateral support, foldable Pelvis support bracket Cover Pelvis support Pad Pelvis support Coverhat, Pelvis support bracket Civer hip support size 3 Zitzi Lumbar support size Lumbar support size Lumbar support size 1 (plastic) Lumbar support size 2 (plastic) Cushion Seat part size 1, Grey (std.) Cushion Seat part size 2, Grey (std.) Cushion lcantara Seat part size 1, lack Cushion lcantara Seat part size 2, lack Leg part size 1, left Leg part size 1, right Leg part size 2, left Leg part size 2, right Rear seat part size Rear seat part size Cover Leg part size 1, lack Cover Leg part size 2, Svart Depth adjustment plate size Depth adjustment plate size Loop, seat slope size Loop, seat slope size Table Plastic size Table Plastic size Table bracket, foldable, size Table bracket, foldable, size Table bracket, reinforced, size Table bracket, reinforced, size 2 - Sharky Pro Locking arm, table (right) Locking arm, table (left) rmrest pad, table size racket Upperarmsupport, right racket Upperarmsupport, left Plate Upperarmsupport size 1-2 (excl. cover) Cushion Upperarm support size rmrest bracket, foldable (back) rmrest bracket, fixed (back) rmrest bracket, right (bottom plate) rmrest bracket, left (bottom plate) rmrest plate size 2, 330x75mm - Zitzi Leg part reinforcement size 1, left Leg part reinforcement size 1, right Leg part reinforcement size 2, left Leg part reinforcement size 2, right Footrest plate, divided 3 (pair) Footrest plate, divided 4 (pair) racket Footrest Footrest profile black 35cm cpl. - Zitzi Footrest profile black 40cm cpl. - Zitzi Footrest profile black 45cm cpl. - Zitzi Hip belt DWSR (spare part) Hip belt 742 (spare part) Knob, M6x Safety strap