Order Form

ORDER FORM
SEAT CUSHIONS
Date :
2016-04-12
Send
P.O.#:
Made for (client) Last name:
First name:
Ordered by :
Establishment :
CONFIRM ORDER BY E-MAIL
Yes 
No 
Address :
SUBSCRIBE TO PHYSIPRO NEWSLETTER
Yes 
No 
Phone :
YOUR EMAIL ADDRESS
Fax :
ALL CUSHIONS INCLUDE ANTIBACTERIAL, FLAME RETARDANT, WATERPROOF COVER AND WATERPROOF INNER COVER
CUSHION SIZES
Width
 14"
 15"
 16"
 17"
 18"
 19"
 20"
 21"
 22"
 23"
 24"
Depth
 14"
 15"
 16"
 17"
 18"
 19"
 20"
 21"
 22"
 23"
 24"
½" or ¼" sizes:
width___________"
Depth___________"
Sizes greater than 24" also available—please contact Physipro customer service
INSTALLATION CHOICE
NOTE : IF NO CHOICE IS MADE THE HARD SEAT OPTION WILL BE
Canvas Seat
Hard Seat
S2980 ABS Reinforcement………….…$75
AUTOMATICALLY SELECTED.
PHYSIPRO SEAT CUSHIONS
C3S
SIZES
Replace latex by urethane ..no extra charge
S2985 : Less than 20" width...................$397 S2987 : 20" or greater width...........................$497
S3000 : Replacement cover……..………… $150 S3005 : Incontinence cover…….……..…….……… $90
Thickness 3"
LXA
 S2455 : 2"...$615  S2455_Pebble : 2"...$925  S2456 : 2 ½"...$635  S2456_Pebble : 2 ½"..$930
 S2458 : 3"...$655  S2458_Pebble : 3"...$940  S2459 : 3½"...$680  S2459_Pebble : 3½"…$945
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 S2996 : 20" or greater width......$1 010
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S2996_Pebble : 20" or greater width......$1 053
Please select the desired thickness for 20" or greater width cushion: 3" 3 ½" 4" 4 ½"
 S2460: Replacement cover…………………………………………$150
 S2465: Incontinence cover…………………..………………………$90
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ULTRA
 Soft Density
 Firm Density
 Replace Viscose by Latex
 S1266 : Less than 20" width…................$550  S1274 : 20" or greater width..…...........................$650
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WITH GEL INSERT
S1278: Flat Gel less than 20" width…..$860 S1278_Pebble: Pebble Gel less than 20" width....$775
S1281: Flat Gel 20" or greater width...$880 S1281_Pebble : Pebble Gel 20" or greater width..$875
S1271: Replacement cover……..………..$150 S1277: Incontinence cover……………….…….………….$90
Thickness 3"
 Soft Density
 Firm Density
 S1265 : Less than 20" width………….....$511  S1269 : 20" or greater width…..….....................$611
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ZERO-PRESSURE
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WITH GEL INSERT
S1276: Flat Gel less than 20" width…..$760 S1276_Pebble : Pebble Gel less than 20" width…..$695
S1286: Flat Gel 20" or greater width....$780 S1286_Pebble : Pebble Gel 20" or greater width..$795
S1270: Replacement cover…………..…....$150 S1330: Incontinence cover…………………….……….…..$90
Thickness 2 ½"
Physipro inc.
370, 10th South Ave., Sherbrooke (Quebec) J1G 2R7 / Phone : 819 823-2252 Toll-Free: 1-800 668-2252 / Fax: (819) 565-3337
Order: [email protected]
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ORDER FORM
SEAT CUSHIONS
S1332-CUSTOMIZED SHAPE—ADD $75
Left
Left
Right
Right
 Low Profile
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Lowered to the :
Right -½" Left -½"
Right -1" Left -1"
Right -1½" Left -1½"
Uneven Depth
Right -1"
Left -1"
2"
 Front Wedge
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Hemiplegic patients
Lowered on one side to keep the
impaired limb elevated, creating a
anti-thrust wedge so the foot of the
functional limb can reach the floor
to facilitate hand/foot propelling.
Front wedge / Low profile
Reduce pressure behind the
knees and hamstrings when the
lower limbs are retracted.
 Right -2"
 Left -2"
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Contoured Depth
Pelvic rotation or hip dislocation can
cause leg length inequality. A choice
of contoured seat depths is available to accommodate these conditions and for propelling with just
one leg.
Anatomic
Relief of this cushion respects
body shapes and thus increases
the contact surface to reduce
pressure. Low-profiled, its shape
allows to put foot on the floor to
facilitate propelling and acts like
an Medial Thigh Abductor.
*If you don't want a customized shape please skip this step.
ANTI-THRUST WEDGE
ANTI-SLING WEDGE
PELVIC OBLIQUITY WEDGE
W
H
H
H
W
D
D
W
P
 S2680 Constructa foam VELCRO……….…....$55
 S2680 Constructa foam GLUED………....…..$55
 S2675 Urethane………………………………..….$44
 Left  Right
 Glued  Velcro
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 S2695 Constructa foam flat……………$83
 Glued  Velcro
 S2670 All Sizes.……..…………………..$39
 Glued  Velcro
Height
1"  1 ½" 
Height
1"  1 ½" 
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2" 
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Height
1"  1 ½" 
2" 
MEDIAL THIGH ABDUCTOR
MEDIAL THIGH ABDUCTOR
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2" 
SHAPED ADDUCTOR WEDGE
D
H
H
H
D
W
w
D
Glued only
 S2726 : W: 2½" H: 3" D: 4"......$50
 S2733 : W: 3" H: 4" D: 6"......$50
 S2736 : W: 3½" H: 5" D: 8"......$50
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 S2725 : W: 3" H: 2" D: 7"....$39
 S2730 : W: 4" H: 2½" D: 7"....$39
 S2735 : W: 5" H: 3" D: 7"....$39
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 Left  Right
 S2965 : H: 2".......................................$61
 S2970 : H: 3".......................................$61
 S2975 : H: 4"…….……………..…………….…$61
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H= Height on top of the cushion
D= Depth ⅖ of the cushion depth
LATERAL PELVIC SUPPORT
LATERAL PELVIC CUSHION
W
H
Glued only
 Left  Right
 S2890 H: 3½" ….............................$61
 S2895 H: 4½" ................................$61
 S2900 H: 5½" ...............................$61
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*Nylon Cover Included
Prevents pelvis rotation
H
D
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VELCRO FASTENER
 Left
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 Right
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Urethane
S2861 W: 1" D: 9½" H: 5½" …...........................$39
S2866 W: 1½" D: 9½" H: 5½"...............................$39
S2871 W: 2" D: 9½" H: 5½.................................$39
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H= Height on top of the cushion
D= Depth ⅗ of the cushion depth
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