Ki Mobility Sparks Order Form - Think Mobility Think Mobility
Transcription
Ki Mobility Sparks Order Form - Think Mobility Think Mobility
MASS Script Form Think Mobility www.thinkmobility.com.au Australian Order Form Effective 01/10/2014 Company: ________________________________________________ Ship To: __________________________________________________ Account Number: __________________ Date: _________________ Address: _________________________________________________ Quote PO Number: ___________________________________ City: ________________________________ State: _____________ RTS: _____________________________________________________ Zip: ________________ Phone: _____________________________ Marked For: _______________________________________________ Email/Fax: ________________________________________________ Spark - Transit Included E1238 ___________________________________ 76 Kg weight capacity. Not available with upholstery. Spark - Transit Not Included E1238 _________________________ 76 Kg weight capacity. Not available with upholstery. Charge Charge Frame Frame Width / Frame Depth Frame Width Spark is set up to allow 2” increase in frame width from initial frame width in 1” increments. Growth is achieved by expanding cross braces. 16” maximum frame width. 10” Frame Width expands only 1”. Select box corresponding to desired Frame Width and Depth. See references at right. Frame Width 12” Frame Depth 13” 14” 15” 16” 17” 18” 10” 11” 12” 13” 14” 15” 16” Frame Depth Spark is set up to allow 4” increase in frame depth from initial frame depth in 1” increments. 19” maximum frame depth. Transit Option Transit System K0108 ___________________________________________________________________Charge No charge when selected with Spark - Transit Included Not available with Removable Seat Pan. Backrest Back Post / Height Range / Back Height Back Post Options Select Back Height in row corresponding to desired Back Post and Height Range. Both Back Post options are folding and angle adjustable in 4º increments. Back Post Price Height Range Standard Depth N/C Adjustable Standard Height Adjustable $75 Depth Adjustable Short Tall Medium Tall Stroller Handle Extensions Charge _________________________________________________________ Not available with Height Adjustable Depth Adjustable Back Posts Seating Dynamics Rocker Back K0108 Charge _______________________________ Available only with T-Arms. Not available with 12” Frame Depths with Rear Frame Heights lower than 14.5”. Back Height 20 24 13 16 20 14 17 21 15 18 22 16 19 23 17 20 24 DCN0033.10 Pricing and specifications subject to change without notice Page 1 of 8 Think Mobility - www.thinkmobility.com.au Footrest Hanger / Front Frame Bend 60º Footplate __________________________________________________________________________________________________________ N/C Available only with Extension Tube Hangers 70º 80º __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ N/C N/C Not available with 7” or 8” Casters 90º __________________________________________________________________________________________________________ N/C Available only with Front Mount Hangers Heel Loops not included Composite ____________________________________________________________________________________________ N/C Not available with Front Mount Hangers or Frame Widths less than 14” Aluminum Angle Adjustable K0040 One Piece Flip Up Angle Adjustable Charge ___________________________________________ K0040 ____________________________Charge Not available with Front Mount Hangers, Elevating Leg Rests or Frame Widths less than 14” Elevating Leg Rests E0990 ___________________________________________________________Charge Not available with One Piece Flip Up Footplate or Heel Loops Omit Hangers ___________________________________________________________________________________ N/C Footrest / Extension / Footrest Length Select Footrest Length in row corresponding to desired Footrest and Extension. Footrest Length of at least 2.5” shorter than Front Frame Height recommended. Measurements based on 70º Hanger Bend. Footrest Extension Footrest Length Extension Tube Hangers Short (60º, 70º, 80º) Long 11 11.5 12 12.5 13 13.5 14 14.5 15 13 13.5 14 14.5 15 15.5 16 16.5 17 15.5 16 16.5 17 17.5 18 18.5 19 19.5 Front Mount Hangers 1 70º / 80º Elevating Leg Rests Short 1 Medium 90º Long 5 5 6 6 12.5 13 13.5 14 7 7 8 8 9 9 13.5 14 14.5 15 14.5 15 15.5 16 Available only with Aluminum Angle Adjustable Footplates 2 11 11 12 122 13 132 142 142 16 16.5 16.5 17 17.5 18 152 162 18.5 Requires 3” Extension at an additional cost Heel Loop Calf Strap Heel Loops E0951 __________________________________________________________________________Charge Not available with Elevating Leg Rests, Foam Loop or One Piece Flip Up Angle Adjustable Footplates or Frame Widths less than 14”. Omit Heel Loops 10 10 ________________________________________________________________________________ DCN0033.10 Pricing and specifications subject to change without notice N/C Not available with Elevating Leg Rests Velcro Adjustable K0038 Padded Velcro Adjustable Padded AeroMesh K0038 Charge Charge ____________________________________________________________Charge _______________________________________________________________ K0038 ______________________________________________ Page 2 of 8 Think Mobility - www.thinkmobility.com.au Front Frame Height and Casters Caster Size / Front Frame Type / Front Frame Height Select Front Frame Height in row corresponding to desired caster size. Note: Selections in first three Front Frame Height columns require Super Low Front Frame for $50 Caster Front Frame Height Size Requires Super Low Front Frame1 1 3” 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 4” 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 5” 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 6” 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 7” 16.5 17 17.5 18 18.5 19 19.5 20 20.5 21 8” 17.5 18 18.5 19 19.5 20 20.5 21 Requires Super Low Front Frame at an additional charge Caster Type Fork Stem .75” Rollerblade __________________________________________________________________________________ N/C Available only with 3 and 4” Caster Sizes .75” Lighted Rollerblade Charge _______________________________________________________________ Available only with 3 and 4” Caster Sizes 1” Poly Best Fit ___________________________________________________________________________________________________ Standard Fork Stem 3/4” Longer Fork Stem 1 1/2” Longer Fork Stem __________________________________________________________________________ ___________________________________________________________________________________________________ N/C Not available with 3” Caster Size 1” Poly Aluminum ____________________________________________________________________________Charge Std Ki Mobility will pick optimal Fork Stem based on Caster Size and Front Frame Height ____________________________________________________________________ _________________________________________________________________ N/C N/C N/C Available only with 4” and 5” Caster Sizes 1” Pneumatic Charge ____________________________________________________________________________________ Available only with 6” and 8” Caster Sizes 1.5” Poly Charge ____________________________________________________________________________________________ Available only with 5” and 6” Caster Sizes 1.5” Soft Roll Aluminum Charge ________________________________________________________________ Available only with 3”, 4”, 5” and 6” Caster Sizes 2” Poly Charge ________________________________________________________________________________________________ Fork Options Frog Legs Fork Charge ______________________________________________________________________________ Available only with 4”, 5” or 6” Casters. Not available with Caster Pin Locks End User Weight Required: ____________ Kgs Caster Pin Locks K0073 _______________________________________________________________Charge Not available with 1 1/2” Longer Fork Stem or Frog Legs Fork Available only with 6” Caster Size 2” Pneumatic w/ Foam Insert Charge _____________________________________________________ Available only with 8” Caster Size Wheel Locks Wheel Lock Wheel Lock Options Push to Lock Pull to Lock Omit Wheel Locks ________________________________________________________________________________________ __________________________________________________________________________________________ _____________________________________________________________________________ DCN0033.10 Pricing and specifications subject to change without notice Std N/C N/C Extension Handles Grade Aids E0974 E0961 Charge Charge ____________________________________________________________ ___________________________________________________________________________ Available only with Push to Lock Wheel Locks Available only with Pneumatic or Pneumatic w/Airless Insert Rear Tire Types Page 3 of 8 Think Mobility - www.thinkmobility.com.au Rear Frame Height and Wheels Wheel Size / Tire Profile / Rear Frame Height Select Rear Frame Height in row corresponding to desired Wheel Size and Tire Profile. Requires curved axle plate. Any axle plate can be used. Wheel Size Tire Profile Rear Frame Height Low 11 11.5 11.5 12 12 12.5 12.5 13 13 13.5 13.5 14 14 14.5 14.5 15 15 15.5 15.5 16 11.5 12 12 12.5 12.5 13 13 13.5 13.5 14 14 14.5 14.5 15 15 15.5 15.5 16 16 16.5 12.5 13 13 13.5 13.5 14 14 14.5 14.5 15 15 15.5 15.5 16 16 16.5 16.5 17 17 17.5 13.5 14 14 14.5 14.5 15 15 15.5 15.5 16 16 16.5 16.5 17 17 17.5 17.5 18 18 18.5 18” Full Low 20” Full Low 22” Full Low 24” Full Axle Plate Standard Curved Amputee Handrim Std Charge ____________________________________________________________________________________________Charge ________________________________________________________________________________________________ ______________________________________________________________________________________________ Rear Wheel Type Spoke Mag Charge ________________________________________________________________________________________________________ N/C Not available with 18” Rear Wheel Size Charge _________________________________________________________________________________ Not available with 18” or 20” Rear Wheel Sizes Color: Handrim: Aluminum Anodized Plastic Coated Projection (8 Vertical Projections) Std Charge _____________________________________________Charge ___________________________________________________________________________ _________________________________________________________________________________ Available only on 22” and 24” Spoke wheels & 24” Mag wheels w/full tires _________________________________________________________________________________________________ Spinergy Spox Standard Handrims Black Red Short Tab White Blue Long Tab Yellow Available only with Aluminum Anodized and Plastic Coated Handrims Rear Tire Type Full Profile Omit Handrim ______________________________________________________________________________________ N/C Natural Fit Handrims Not available on 18” or 20” wheels or 22” Mag wheels Natural Fit LT Regular Grip Natural Fit Standard Regular Grip Natural Fit LT Super Grip Natural Fit Standard Super Grip Natural Fit LT Omit Grip Natural Fit Standard Omit Grip Charge Charge _____________________________________________________________Charge ________________________________________________Charge _______________________________________________________________Charge __________________________________________________Charge __________________________________________________________ _____________________________________________ Handrim Option Street Pneumatic 1 3/8” Full Profile Poly 1 3/8” E2218 Pneumatic with Airless Insert 1 3/8” Std _______________________________________________________Charge E2211, E2213 _________________Charge ___________________________________________________________________ 3M Micro Grip Charge _________________________________________________________________________________ Not available on Plastic Coated or Projection Handrims Low Profile Low Profile Poly 1” E2218 Shox Solid Tire 1” E2218 Charge Charge _____________________________________________________________ _______________________________________________________________ Available only on 24” wheels High Pressure 1” E2211, E2212 _____________________________________________________Charge Not available on Mag, 18” or 20” wheels Axles Axle Axle Position Quick Release Quad Quick Release Std Charge ______________________________________________________________________________________ ______________________________________________________________________ Not available with Mag wheels DCN0033.10 Pricing and specifications subject to change without notice Rear Wheel Camber: Center of Gravity: 0º Rear 2º Center 4º Forward Page 4 of 8 Think Mobility - www.thinkmobility.com.au Armrests Armrest Armrest Please select Arm Pad option Height Adjustable T-Arm (8.5” - 13.5”) E0973 Not available with Frame Depths less than 14” Charge ______________________________ Angle Adjustable Locking Extendable Flip Up continued Tubular Flip Up ____________________________________________________________________________________ N/C Not available with Arm Pads or Frame Widths greater than 14". E0973 Charge ___________ Pediatric Height Adjustable T-Arm Desk (6.5” - 10”) E0973 Charge __ User weight limit: 165 lbs. Omit Armrests Arm Pad _____________________________________________________________________________________ N/C Not available with Tubular Flip Up or Pediatric Height Adjustable T-Arm Desk Armrests Desk Full Accessories Removable Side Guard Seat Pan Not available with Height Adjustable T-Arm Armrests Adult Composite Side Guards (14” - 16”) K0108 Pediatric Composite Side Guards (10” - 14”) K0108 Charge _______________Charge Removable Aluminum Seat Pan E2231 __________________________________Charge Not available with Transit System. Pan depth 1/2” shorter than Frame Depth. ______________________ Other Accessories Anti-Tip Rear Anti-Tips E0971 Charge _____________________________________________________________________ Tool Kit Underseat Pouch Charge Charge ______________________________________________________________________________________________ ___________________________________________________________________________ Not available with 10” - 13” Seat Widths Positioning Belt Charge Charge _____________________________________________________________Charge ____________________________________________Charge __________________________________________________________________Charge E0978 ____________________________Charge ____________________________________________________________________ ____________________________________________________ Small (16-24”) Medium (19-29”) Bodypoint Belt Mounting Kit Style: Charge Charge _________________________________________________________Charge ____________________________________________________________________ 1” Auto Buckle E0978 1” Padded Auto Buckle E0978 1 1/2” Auto Buckle E0978 1 1/2” Padded Auto Buckle E0978 2” Airline Buckle E0978 Bodypoint Evoflex - Pelvic Stabilizer Size: Ki Mobility Backpack Black Neoprene Impact Guards Clear Spoke Guards K0065 Bracket ________________________________________________ Not available with Mag wheels Black Spoke Guards K0065 ________________________________________________________Charge Not available with 18” or 20” wheels or Mag wheels Cane and Crutch Holder Charge _____________________________________________________________ Large (25-37”) Charge ______________________________________________________ Band Clamp 1” Frame Color Gloss Finish Matte Finish Black Blue Skies Bubblegum Pink Candy Blue Candy Purple Candy Red Copper Fuchsia Granny Smith Orange ______________________________________________________________________________________________________ ____________________________________________________________________________________________ _________________________________________________________________________________ __________________________________________________________________________________________ ______________________________________________________________________________________ ___________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ______________________________________________________________________________________ __________________________________________________________________________________________________ N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C Emerald Green Graphite Gray Iridescent Burgundy Iridescent Navy Retro Red Royal Blue Shadow Black Smooth White ____________________________________________________________________________________ ______________________________________________________________________________________ __________________________________________________________________________ ___________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ N/C N/C N/C N/C N/C N/C N/C N/C Graphic Image Transfer Visit www.kimobility.com for current graphic image transfer options Note selection below DCN0033.10 Pricing and specifications subject to change without notice Charge Page 5 of 8 Think Mobility - www.thinkmobility.com.au Therafin Accessories Vest Knee Adductor Charge Full Shape, Comfort Strap (E0960) Small 30589 Medium 30590 Large 30591 X-Large 30592 2X-Large 30593 Charge Full Shape, Extended Strap (E0960) Small 30594 Medium 30595 Large 30596 X-Large 30597 2X-Large 30598 Charge Trip Shape, Comfort Strap (E0960) Small 30618 Medium 30619 Large 30620 X-Large 30621 2X-Large 30622 Trim Shape, Extended Strap (E0960) Charge Medium 30624 Large 30625 Small 30604 X-Large 30626 2X-Large 30627 __________________________________________ ________________________________________ _________________________________________ _____________________________________ Shoulder Harness With metal clips and cam locks Small (E0960) 61403 Medium (E0960) 61503 Large (E0960) 61703 X-Large (E0960) 61803 Charge Charge Charge Charge ______________________________________________________________________ _________________________________________________________________ ______________________________________________________________________ __________________________________________________________________ Hip Belt 4 Point Y-Style, Metal Buckle (E0978) Small 60024 Medium 60025 Large Dual Rear Pull, Metal Attaching Clips (E0978) 1” Straps, 6.25”W x 1.75”H Pads 60161 1.5” Straps, 7.25”W x 2.25”H Pads 60171 1.5” Straps, 9.25”W x 2.5”H Pads 60181 Single Pull, Metal Buckle (E0978) 1” Straps, 4.25”W x 1.75”H Pads 61001 1” Straps, 5.25”W x 1.75”H Pads 61101 1” Straps, 6.25”W x 1.75”H Pads 61201 1.5” Straps, 5.25”W x 2.25”H Pads 62001 1.5” Straps, 7.25”W x 2.25”H Pads 62101 1.5” Straps, 9.25”W x 2.5”H Pads 62201 2” Straps, 9.25”W x 3”H Pads 64001 2” Straps, 11.25”W x 3”H Pads 64101 Charge ____________________________________ 60026 Flip Down Hardware (E1028) _____________________________________________________Charge Sold in pairs, one right side and one left side. Short Arm, Fits 3/4”, 7/8” and 1” Tubing Long Arm, Fits 3/4”, 7/8” and 1” Tubing Knee Adductor Pad with Neoprene Cover (E0956) 30248 30284 Charge ____________ Sold single. Small Pad, 4.25” x 3.25” 50490 Medium Pad, 6.25” x 4.25” 50491 Quantity: ____ Quantity: ____ Foot / Shoe Holder Compatible only with Angle Adjustable Footplates FootSure Ankle Support (K0108) Charge ______________________________________________ Sold in pairs. X-Small w/ Buckle Closure, 6”-8” Circum. 60250 Small w/ Buckle Closure, 7”-8.5” Circum. 60251 Medium w/ Buckle Closure, 8”-11” Circum. 60252 Large w/ Buckle Closure, 9”-12” Circum. 60253 X-Large w/ Buckle Closure, 12.5”-15” Circum. 60254 X-Small w/ Hook-N-Loop Closure, 5”-6” Circum. 60255 Small w/ Hook-N-Loop Closure, 6”-8” Circum. 60256 Med w/ Hook-N-Loop Closure, 8”-10.5” Circum. 60257 Large w/ Hook-N-Loop Closure, 9”-12” Circum. 60258 X-Lrg w/ Hook-N-Loop Closure, 12”-15” Circum. 60254 Padded Footbox (K0108) Small, Full Design, Fits 14” Chair 30111 Medium, Full Design, Fits 16” Chair 30112 Large, Full Design, Fits 18” Chair 30113 Small, Split Design, Fits 14” Chair 30152 Medium, Split Design, Fits 16” Chair 30153 Large, Split Design, Fits 18” Chair 30154 Molded Shoe Holders (K0108) Charge Charge Charge Charge Charge Charge Charge ______________ _________ Charge Charge Charge ____________ ________ ___________ _____________ ____________ _______ ___________ Charge Charge Charge Charge Charge Charge Charge Charge ____________ ____________ ____________ ________ ________ __________________________________________________ Sold in pairs. Small with Plain Straps, 3.5” x 2.25” 30292 Medium with Plain Straps, 4” x 6.5” 30303 Large with Plain Straps, 4.75” x 8” 30309 X-Large with Plain Straps, 5” x 10” 30316 ___________ __________________ ________________ Cane Mounted Swing Away Lateral Thoracic Support Sold as pair Swing Away Kits w/ 4”x6” Gel Pads (E0956, E1028) Swing Away Kits, No Pads (E0956, E1028) 50022 Charge Charge 50021 ________________ DCN0033.10 Pricing and specifications subject to change without notice Page 6 of 8 Think Mobility - www.thinkmobility.com.au Therafin Accessories continued Half Tray Communication Mount Hardware Standard Shape, Clear, Flip-Away (E0956, E1028) Right Side 41310 Left Side 41311 Standard Shape, Padded, Flip-Away (E0956, E1028) Right Side 41350 Left Side 41353 Trimline Shape, Padded, Flip-Away (E0956, E1028) Right Side 41352 Left Side 41351 Charge ________________ Choose Device Holder AND Mount STEP 1: What DEVICE will be used? Clear Tray with Border and Pre-Drilled Holes Smart Phone 32359 Large Smart Phone I-Pad 32355 I-Pad Mini 32356 7” Tablet 32357 10” Tablet 32358 STEP 1: Choose Tray STEP 2: Where does it need to MOUNT? Charge __________ Charge ____________ Charge Charge Charge Charge Charge Charge ______________________________________________________________________ 32354 __________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________ ______________________________________________________________________________ Chair Width 10” 11” 12” 13” 14” 15” 16” Tray Dimension (WxD) Body Cutout (WxD) HCPCS Part Number ___________________________________________________________________________ Frame 32350 Armrest 32351 Tray 32352 Charge Charge Charge ___________________________________________________________________________________ Price ________________________________________________________________________________ ________________________________________________________________________________________ 17 x 15 7.5 x 4.5, H2.75 E0955 33203 $ 17 x 15 7.5 x 4.5 E0950 33204 $ 17 x 15 8x5 E0950 33205 $ 18 x 16 8.5 x 5 E0950 33206 $ 18 x 16 9.5 x 5.5 E0950 33207 $ 19 x 18 9.5 x 5.5 E0950 33208 $ 19 x 18 10.5 x 6 E0950 33209 $ 20 x 18 10.5 x 6 E0950 33210 $ 20 x 18 11.5 x 6.5 E0950 33211 $ 21 x 18 11.5 x 6.5 E0950 33212 $ 21 x 18 12.5 x 7 E0950 33213 $ 22 x 21 12.5 x 7.5 E0950 33214 $ 22 x 21 13.5 x 8.5 E0950 33215 $ Cup Holder Heavy Duty 30889 _________________________________________________________________________Charge Compatible only with Height Adjustable Dual Post Flip Back Armrests STEP 2: Choose Tray Hardware E-Z Lock Clamps, Standard (E1028) 31098 Charge ___________________________ Sold in Pairs DCN0033.10 Pricing and specifications subject to change without notice Page 7 of 8 Think Mobility - www.thinkmobility.com.au Spark Front Frame Height Matrix 3” Caster FSH Stem 4” Caster Fork 14.5 FSH Stem 5” Caster Fork 15 Std Stem 16 Std Fork FSH 15.5 4” 15.5 3/4 3/4 17.5 1 1/2 4” 3/4 15.5 FSH Stem FSH 18 Std 19 18.5 3/4 19.5 1 1/2 16.5 Std 5” Stem Fork 19.5 19.5 5” 18 3/4 18 18.5 1 1/2 16.5 8” Caster Std 17.5 17.5 16 16.5 1 1/2 16.5 4” 16 16 Fork 7” Caster Std 15.5 15 Stem 17 Std 15 3/4 FSH 6” Caster 18.5 6” 20 Std 20.5 1 1/2 1 1/2 17 17 19 19 21 15.5 16.5 17 18.5 19 Std 16 16 Std 17 3/4 5” 17.5 19 3/4 6” 19.5 Std 16 3/4 16.5 17.5 18 19.5 20 16 17.5 18.5 19.5 20.5 17.5 20 Std 5” 16.5 17 16.5 3/4 5” 18 1 1/2 1 1/2 21 1 1/2 17.5 17 18.5 18 3/4 16.5 17 20.5 19.5 16.5 18.5 18.5 20 17 19 19 20.5 19.5 Std 3/4 6” 17 7” 6” 17.5 1 1/2 Std 17.5 3/4 18 17.5 18.5 16.5 18 19 Std 21 20 20.5 19.5 20.5 21 20 19 18 17.5 19.5 8” x 2” caster not available with 6” fork 18.5 18 20 18 18 18.5 18 18.5 1 1/2 17 Std 17 17.5 17.5 3/4 17 17.5 3/4 6” 1 1/2 6” 7” 3/4 20.5 Std 19 21 19 19.5 20 19 19.5 18 20.5 18 18 18.5 1 1/2 18.5 1 1/2 1 1/2 21 7” 18.5 Std 18.5 19 3/4 Std 19 18.5 19 19.5 19.5 20 18.5 19 7” 19 3/4 19.5 19 7” 19.5 3/4 19.5 1 1/2 19.5 20 20 20.5 1 1/2 20 19.5 20 1 1/2 6” x 2” caster not available with 5” fork 20.5 Frame heights available with Standard Front Frame. Subtract 1 1/4” when using Super Low Front Frame. Actual frame height may vary up to 1/4”. DCN0033.10 Pricing and specifications subject to change without notice Page 8 of 8 Notes Custom Information Notes and sketches/additional information in detail