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Page 1 of 601OCT2018
AADL Legrests and Armrests Order Form
This form is interactive when viewed with Adobe Acrobat Reader. Complete the form by placing checks in the desired boxes and provide information in the interactive fields. Buttons shown at the bottom of the form may be utilized to print or submit the order form through a desktop email application. To email via a web-based application, please ‘Save As’ and at-tach the PDF to your email. This order form contains a large variety of options to fulfill various patient needs. Descriptions and section notes, such as optional or required, are included to help you complete your order. Other part numbers can be found on the quote ac-knowledgment after this order form is submitted. Please contact Quantum® Sales at 888-570-1113 if assistance is needed. Send the completed order form by fax (866-514-1303) or email (productorders@pridemobility.com). Incomplete forms may delay the quote or order. Customer service will contact you if the order is incomplete or if there are compatibility issues. If special order requests are needed, be sure that the Patient Information section is completed All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete power chair. Please contact technical service for accurate parts ordering.
Please include serial number to ensure compatibility.
Serial number: ___________________________________
Pride Mobility Products Co. FOR AADL USE ONLY 5096 South Service Rd, Beamsville, ON, L0R 1B3Phone: 888-570-1113 | Fax: 866-514-1303 | Email: tech-ca@pridemobility.com
INTRODUCTION
Account Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City:_________________ Prov:______Postal:_________
Alberta Health - Pharmaceutical and Supplementary Benefits Alberta Aids to Daily Living Parts Prices - Pride Mobility Legrests and Armrests
© 2019 Government of Alberta March 22, 2019
Page 2 of 601OCT2018
QUANTUM POWER CHAIR ARMRESTS
TRU-Balance 3 Flip-Back, 8”-12”H .................. $145 ea. TRU-Balance 3 RIGHT Flip-Back, 12”-16”H ........ $145 ea.
TRU-Balance® 3 Flip-Back Armrests
Set RIGHT height at:______Set LEFT height at:______
TRU-Balance 3 Armrest Downpost (Pair) .......................................................................................................$95 ea.
Heavy Duty, Removable Armrests
8”-12”H, Single Post, Height Adjustable, ............. $130 ea.Removable, Heavy Duty
10”-14”H, Single Post, Height Adjustable, ............ $130 ea.Removable, Heavy Duty
Set LEFT height at:______ Set RIGHT height at:______
2-Post, Flip Back, Height Adjustable, and Removable Armrests (9”-13” Height) .......................................................$145*
Two-Post ArmrestsSelect the armrest and set the left and right heights. These armrests may interfere with offset backs/ back canes.
Set RIGHT height at:______Set LEFT height at:______
No Armpad Selection and/or See Positioning Components Page or Order Form .................................................. No Charge
Straight, Armpad ......................................... $16 ea. Waterfall, Armpad ........................................ $16 ea.
Falcon Gel ArmpadsSold only in pairs. Select an armpad set below. Armpads are 3” wide. The mounting plate allows the armpad to be offset from the armrest tube.
Foam ArmpadsSelect a left and right standard type armpad (mix or match) OR choose the gel armpads that follow.
Falcon Gel Left and Right Armpad:Full Length .................................................... $150 eaDesk Length .................................................. $100 eaFor use with TB3 standard armrests.
Falcon Gel Left and Right Armpad with Mounting Plate:Full Length. ................................................... $150 eaDesk Length .................................................. $100 eaFor use with 2-Post, Heavy Duty Removable, or Pediatric Armrests.
ARMPADS
14” Full Length 10” Desk Length
ARMREST SIZEREQUIRED. Select a Left (L) and Right (R) armrest size. This also affects the armpad selection below.
Pediatric, Removable Armrests
Pediatric, Height Adjustable, ........................... $145 ea.Removable
Set LEFT height at:______ Set RIGHT height at:______
Alberta Health - Pharmaceutical and Supplementary Benefits Alberta Aids to Daily Living Parts Prices - Pride Mobility Legrests and Armrests
© 2019 Government of Alberta March 22, 2019
Page 3 of 601OCT2018
QUANTUM POWER CHAIR legrests
5”x6” Footplates 5”x8” Footplates 5”x11” Footplates
Center Mount Footplates
8”-12” ExtensionN/A with Power Articulation.
10”-16” Extension 13”-19” Extension
Center Mount Lower Extension
Center Mount Foot PlatformsIf power articulating foot platform is selected, be sure power legrest control has been selected in previous section.
Power ArticulatingFoot Platform
Set Length at:______
Power Articulating Foot Platform ..........................$3,145Not covered by AADL
Manually Adjustable Center Mount .......................... $265Foot Platform
Small Calf Pad (pair) 6”Wx6”H ................................ $210
Large Calf Pad (pair) 8” taper to 6”Wx8”H ................ $210
Small Calf Panel 18”Wx8”H ................................... $210
Large Calf Panel 24”Wx8”H ................................... $265
Center Mount Calf Support
Width Extension, 8”D and 11”D Footplates .................$55
2” Bell-Shaped Length Extension ..............................$55
4” Outside Edge ...................................................$55
6” Outside Edge ....................................................$55
Reversed Dartex Calf Pad or Panel Cover (pair) .......... $150
Wheel Bumpers (pair) ............................................$30
Footplate Connector ..............................................$55
Modular Footplate Extension Components
Additional Accessories
70° HD Drop-in with 12"-14.5" ....................... $550 Length Lower Extension
Pair part: FRMASMB4762. Left: RIG137706. Right:
RIG137707
70° HD Drop-in with 14.5-18" ........................ $550
Heavy Duty, Drop-in Legrest UpperLeft and Right Legrests will match Left and Right Legrests will not match One Legrest (Left or Right as Marked)
Configuration Verification
Heavy Duty, 70°, Drop-In, Swing-Away LegrestsSelect a configuration, a legrest with extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.
Accessories
6”Wx8”D1 ..........................................$87.50 ea.Pair part: FRMASMB4738. Left: RIG137793. Right: RIG137795.
6”Wx11”D1 .........................................$87.50 ea.Pair part: FRMASMB4741. Left: RIG137796. Right: RIG137797.May cause interference on seat widths less than 18".
8”Wx11”D2 .........................................$87.50 ea.Pair part: FRMASMB4744. Left: RIG137708. Right: RIG137709.May cause interference on seat widths less than 20".
Wheel Bumper(s) ...........................................................................................................................$15 ea.Pair part: WHLASMB1578. Left part: WHL169510. Right part: WHL169511
Angle Adjustable Footplate(s) with Heel Loops
Alberta Health - Pharmaceutical and Supplementary Benefits Alberta Aids to Daily Living Parts Prices - Pride Mobility Legrests and Armrests
© 2019 Government of Alberta March 22, 2019
Page 4 of 601OCT2018
70° Articulating, Swing-Away Legrests (pair) ............................................................................................ $2,865
11”-13” Length 114.5”-18” Length
Lower Extension
Power Articulating, Swing Away Legrests
Left and Right Legrests will Match Left and Right Legrests will not match One Legrest (Left or Right as Marked)
Configuration Verification
70° Power Articulating, Swing Away Legrests
Set Length at:______
Calf Pad (pair) 6”Wx6”H ................................ No Charge Gel Padded Knee Abductor Buttons (pair) ................. $125INDPART2242
Accessories
4”Wx6”D 5”Wx6”D 5”Wx8”D 6”Wx8”D1 6”Wx11”D1 8”Wx11”D2
Angle Adjustable Footplate¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.
60°-90° Swing-Away Legrest ....................................................................................................................$285
60°-90° Swing-Away Legrests
Swing-Away Legrest Upper
Left and Right Legrests will match Left and Right Legrests will not match One Legrest (Left or Right as Marked)
Configuration Verification
11”-13” LengthN/A with Multi-axis
11”-16.5” LengthOnly with Multi-Axis
13”-16.5” LengthN/A with Multi-Axis
15.5”-19.5” Length
Lower Extension
Set Length at:______Extruded Footplate(s)
Angle Adjustable or Multi Axis Selection
7.25”Wx6”D Extruded Footplate ....................Standard 8.5”Wx6”D Extruded Footplate .....................StandardMay cause interference on seat widths less than 18.”
Angle Adjustable with Heel Loops ................$87.50 ea.(Select footplate size)
Multi-Axis (Select Footplate Size) ................... $260 ea.
4”Wx6”D 5”Wx6”D 5”Wx8”D 6”Wx8”D 6”Wx11”D1 8”Wx11”D2
Angle Adjustable or Multi-Axis Footplate Size¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.
Heel Loops (pair) ..................................................$35Part: FRMASMB7873 Standard on angle adjustable and multi-axis footplates.
Wheel Bumpers (pair) ............................................$30
Gel Neoprene Footrest Sleeve (pair) ........................ $130Part: INDPART2243
60°-90° Swing-Away Legrest Accessories
Alberta Health - Pharmaceutical and Supplementary Benefits Alberta Aids to Daily Living Parts Prices - Pride Mobility Legrests and Armrests
© 2019 Government of Alberta March 22, 2019
Page 5 of 601OCT2018
AccessoriesHeel Loops (pair) ..................................................$35Part: FRMASMB7873 Standard on angle adjustable footplates.
Wheel Bumpers (pair) ............................................$30
Falcon LPW Gel Padded Adductor Buttons (pair) ......... $125Part: INDPART2242
Elevating Legrest Assembly ............................... $550Select lower extension and footplates
HD Elevating Legrest Assembly ........................... $550Select lower extension and footplates
Elevating LegrestLeft and Right Legrests will match Left and Right Legrests will not match One Legrest (Left or Right as Marked)
Configuration Verification
11”-14” LengthFor reinforced only
12”-14.5” LengthFor angle adjustable only
14”-17” LengthFor reinforced only
14.5”-18” LengthFor angle adjustable only
Lower Extension
Reinforced Cast Footplate(s)7.25”Wx6”D Reinforced Footplate ..................Standard
8.5”Wx6”D Reinforced Footplate ...................StandardMay cause interference on seat widths less than 18.”
Angle Adjustable with Heel Loops ................$87.50 ea.(Select footplate size below)
4”Wx6”D 5”Wx6”D 5”Wx8”D 6”Wx8”D1 6”Wx11”D1 8”Wx11”D2
Angle Adjustable Size¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.
Set Length at:______
Elevating Legrests
Angle Adjustable Footplate(s)
Alberta Health - Pharmaceutical and Supplementary Benefits Alberta Aids to Daily Living Parts Prices - Pride Mobility Legrests and Armrests
© 2019 Government of Alberta March 22, 2019
Page 6 of 601OCT2018
Swing-Away (Retractable), Offset Bracket
LITESTREAM MANUAL CHAIR ARMRESTS
Armrests:oTubular Swing-Away 12’’ $290 oSingle Post Height Adjustable Arm (9”-14”H) $315 Armpads
oFull Length, Straight
oDesk Length, Straight
oFull Length, Waterfall
oDesk Length, Waterfall
oHeight Adjustable Dual Post, Flip-Back, Removable1,2 (10.5’’-15.5’’H) $290 Armpads
oFull Length, Straight
oDesk Length, Straight
oFull Length, Waterfall
oDesk Length, Waterfall
LITESTREAM MANUAL CHAIR legrests
Upper:
o60o Swingaways $235
o70o Swingaways $235
o90o Swingaways2,Page1 $235
oElevating Legrests w/ Standard Calf PadsPage2 $415
oElevating Legrests w/ Depth Adjustable Calf Pads $415 Lower:
oShort
oMedium
oLongPage3
Footplates:
oFlip-up Alum Footplate w/Heel LoopPage4 Std
Footplate Size:
o6.5"x 6"Page5o8”x 6"
oComfort Adjustable Composite $135
o4.25’’ o5’’ o6’’
oHeel Loops $40
oAluminum Angle Adjustable $235
o5.5’’ o6.5’’ o7.5’’
oHeel Loops Std
oOmit Heel Loop
oWheel Bumpers $30 Not covered by AADL
Alberta Health - Pharmaceutical and Supplementary Benefits Alberta Aids to Daily Living Parts Prices - Pride Mobility Legrests and Armrests
© 2019 Government of Alberta March 22, 2019
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