Zip Code: Zip Code:
1
STFH - Tilt & Lift
1
STFH - Tilt & Lift
□
18 ¾ " (B & C)
□
19 ½ " (A & C)
□
19 " (B & C)
□
19 ½ " (A & C)
□
19 " (A & C)
□
17 ½ " (A & C)
□
18 ¾ " (A & C)
□
19 " (A & C)
□
19 " (A & C)
□
19 " (A & C)
□
M11: 18 ¼ " F11: 19 ¼ " (A & C)
□
19 " (A & C)
□
TBA (B & C)
□
19 " (A & C)
□
19 ½ " (B & C)
□
18 ¾ " (A & C)
□
N/A
□
19 " (B & C)
□
N/A
□
19 " (A & C)
□
TBA (A & C)
□
TBA (B & C)
□
19 " (A & C)
□
18 ½ " (A & C)
□
19 ½ " (A & C)
□
20 " (A & C)
□
RFQ
□
A -
B -
PRIDE (QUANTUM) INVACARE
3
□
Q-Logic
□
MK690ACC
5
□
MK690
3
□
Q-Logic NE+
□
MK5-EX
□
MK5-NX
4
□
Q-Logic NE
□
MKIV-A
□
MKIV-RII
□
6-Key VR2
□
Std VR2
□
MK6TT
□
GTRAC
□
Remote Plus
Joystick Type
□
SPJ
□
MPJ
□
6-Key VSI
□
Std VSI
OTHER MANUFACTURER
4
□
Dynamic Shark
□
Specify: __________________
5
6
Seat to Top of Scapula Height: _______________ "
The order cannot be processed without the following:
- A user name or number, the client’s measurements and weight
- Amysystems is not responsible for configuration or size discrepancies resulting from customer errors on the order form.
- Order confirmations will be provided by Amysystems summarizing the items selected. Please review this carefully.
- Once the order is shipped, any changes are subject to the returns policy and may be prohibited.
Seat Cushion Thickness: _______________ "
Innovation In Motion - X8 Extreme
User Name or Number: ____________________________________________________________
User Weight: _______________ Lbs
Knee to Heel: Left: _______________" Right: _______________"
Seat to Elbow Height: _______________ "
User Height: _______________ Feet _______________ Inches
15 ½ " (B)
Quickie Freestyle
□
M11
□
F11
17 " (B)
Permobil Model: _____________________Permobil Model: _____________________ RFQ
POWER BASE SELECTION
Requires either the TAM or CLAM interface from Innovation in Motion
16 ¼"-17 ¼" (B)
Invacare Pronto M91 17 " (B)
I.I.M.
Dynamic
17 " (B)
Quantum 610
Quantum 600
FOOTNOTES
300AOther Power Wheelchair Base. Specify:
17 " (B)
16 ½ " (B)
Quickie Rhythm
Phone Number:
Fax Number:
16 ¼ " (B)
16 ½ " (B)
17 ¼ " (A)
2
Quickie S525
□
Narrow
□
Std
□
Wide
Contact:
Address:
Email Address:
16 ¾ " (B)
Quantum
□
6000Z
□
6400Z
FOR INTERNAL USE ONLY
equipped with a female Redel "Pigtail" connector in order to obtain 24V power and drive lock-out.
2
Quantum R4000
C - Seat Lift 300
Quantum Q6 Edge
1
300B
Note: For a tilt only with a Long seat pan range
up to 22", please replace the 300-B tilt and
use the 300-A tilt. Seat to floor height may
increase by up to ¾".
19 " (A)
ELECTRONICS (INCLUDED WITH POWER WHEELCHAIR)
Invacare TDX SP
□
Group 22
□
Group 24
18 ½ " (A)
Innovation In Motion - Frontier V6
2
Quickie P220 / P222
□
Std.
□
Wide
When a chair is equipped with an 11" seat lift and Q-Logic electronics, reduced speed requires
6
□
G90T
3
going through drive controls. Please select one of these part numbers for reduced speed:
6
□
90A
□
DX2
6
□
Dolphin
6
□
DX G90
SWTJSS, SWTJSD or SWTJSM.
QUICKIE
□
Qtronix
□
Delphi
□
6-Key VSI
□
Standard VSI
□
R-net
□
R-net EL
□
Standard VR2
□
6-Key VR2
1
STFH - Tilt
□
P&G R-net
17 " (B)
The Q-Logic NE is not compatible for through the joystick operation or reduced speed.
Base permitting, group 24 batteries can be used to power the wheelchair.
17 " (B)
(STFH) Seat to floor height is measured at the front of the seat pan with a 0° Pre-Tilt.
For the Quickie S-525 and the P220 / P222 with VSI electronics, they must be tilt ready and
17 " (B)
18 ½ " (A)
Wheelchair ModelWheelchair Model
Golden Compass
Quickie Pulse 6
Invacare TDX SR
Quantum J6
17 ¼ " (A)
SHIP TO:BILL TO: (For Invoicing, if Different then "Ship To" Location)
November 1, 2014
Dealer Name:
The maximum standard user
weight capacity is 300 lbs
Dealer Name:
Quote/Order Number:
INFORMATION ON THE USER
City:
Phone Number:
State:
Email Address:
Contact:
ORDER / QUOTE INFORMATION
P.O. Number:
Date:
Address:
City:
State:
Fax Number:
Invacare TDX SC (Spree)
Invacare
□
TDX3
□
TDX4
□
TDX5
17 " (A)
16 ½ " (B)
16 ¾ " (B)
Amypower Alltrack Rear-Wheel
□
R
□
P
1
STFH - Tilt
Amypower Alltrack Mid-Wheel
□
M
□
P Invacare Storm 3G
□
Short
□
Long
17 " (A)16 ¾ " (A)
MK690 is not compatible to be used with power seating options.
Invacare FDX TBA (B) Quantum Rival TBA " (B)
Quickie
□
QM710
□
QM720
Quickie S636 / S646 SE
□
Std.
□
Wide
TBA (B)
Specifications are subject to change without notice. Copyright @ 2014, Amylior Inc. (November 2014) AMYSEAT - USA (Rev. 1)
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