invacare matrx backs us price list/order form …freedomdesigns.com/literature/sp...

INVACARE® MATRX® BACKSUS PRICE LIST/ORDER FORM

Effective November 1st, 2014

1.888.433.6818 FAX: 1.888.433.6834 1 of 22 TRD0366 REV E

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________

Purchasing Contact: __________________________________________

Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________

Pediatric Backs 4 Page

Invacare® Matrx® Mini Back/Extra Outer Cover 2

Standard Backs 4 Page

Invacare® Matrx® PB Back/Extra Outer Cover 3Invacare® Matrx® PB Deep Back/Extra Outer Cover 3Invacare® Matrx® Elite Back/Extra Outer Cover 6/7Invacare® Matrx® Elite Full Back/Extra Outer Cover 7Invacare® Matrx® Elite TR Back/Extra Outer Cover 8Invacare® Matrx® Elite Deep Back/Extra Outer Cover 9Hardware Upgrades for Matrx Elite and PB Backs 13/14/15Invacare® Matrx® MX1 Back/Extra Outer Cover 18/19Hardware Upgrades for Matrx MX1 Back 20Invacare® Matrx® Genera Back/Extra Outer Cover 20

Bariatric Backs 4 Page

Invacare® Matrx® PB Heavy‐Duty Back/Extra Outer Cover 4Invacare® Matrx® PB Extra Wide Heavy‐Duty Back/Extra Outer Cover 4Invacare® Matrx® PB Deep Heavy‐Duty Back/Extra Outer Cover 5Invacare® Matrx® PB Extra Wide Deep Heavy‐Duty Back/Extra Outer Cover 5Invacare® Matrx® Elite Deep Heavy‐Duty Back/Extra Outer Cover 10Invacare® Matrx® Elite TR Heavy‐Duty Back/Extra Outer Cover 10Invacare® Matrx® Elite Heavy‐Duty Back/Extra Outer Cover 11Invacare® Matrx® Elite Extra Wide Heavy‐Duty Back/Extra Outer Cover 11Hardware Upgrades for Matrx Elite and PB Backs 13/14/15

Modifications & Accessories 4 Page

Invacare® Matrx® Elite & Mini Back Laterals 12Matrx® PB & Elite Back Options and Modifications 16/17Military Service Emblems 17Headrest Supports & Hardware 21Other Accessories 22

NOTE: ITEMS HIGHLIGHTED IN GREEN ARE AVAILABLE THROUGH MOTION CONCEPTS ONLY

1 of 91 (800) 331-8551 FAX: 1(888) 582-1509 FDMOCC 11.2015 REV. A

INVACARE® MATRX® CUSHIONSUS PRICE LIST/ORDER FORM


1.888.433.6818 FAX: 1.888.433.6834 1 of 15 TRD0365 REV D

Pediatric Cushions 4 Page

Invacare® Matrx® Kid*ab*ra Cushion/Extra Outer Cover 2

Invacare® Matrx® Kid*ab*ra®Kid*ab*ra Drop Base/Extra Outer Cover 2

Invacare® Matrx® PS Cushion/Extra Outer Cover 6

Standard Cushions 4 Page

Invacare® Matrx® Vi Cushion/Extra Outer Cover 3Invacare® Matrx® Vi Drop Base/Extra Outer Cover 4Invacare® Matrx® Vi Cushion Rigidizer 4Invacare® Matrx® PS Cushion/Extra Outer Cover 7Invacare® Matrx® Libra Cushion/Extra Outer Cover 9Invacare® Matrx® Flo‐tech Cushion/Extra Outer Cover 12

Bariatric Cushions 4 Page

Invacare® Matrx® Vi Heavy‐Duty Cushion/Extra Outer Cover 5Invacare® Matrx® PS Heavy‐Duty Cushion/Extra Outer Cover 8Invacare® Matrx® Libra Heavy‐Duty Cushion/Extra Outer Cover 10Invacare® Matrx® Flo‐tech Heavy‐Duty Cushion/Extra Outer Cover 13


Invacare® Matrx® Libra Fit Kit Components 11Invacare® Matrx® Flo‐Tech Fit Kit Components 14Cushion Modifications 15Cushion Accessories 15Cushion Hardware

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________


® INVACARE® MATRX® CUSHIONSFREEDOM DESIGNS ON-CHAIR ORDER FORM




1.888.433.6818 FAX: 1.888.433.6834 1 of 15 TRD0365 REV D











Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________




1.888.433.6818 FAX: 1.888.433.6834 1 of 15 TRD0365 REV D











Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________


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1.888.433.6818 FAX: 1.888.433.6834 1 of 22 TRD0366 REV E

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________











INVACARE® MATRX® CUSHIONS – FREEDOM DESIGNS ON-CHAIR ORDER FORMINVACARE® MATRX® CUSHIONS – US PRICE LIST/ORDER FORM

1.888.433.6818 FAX: 1.888.433.6834 2 of 15 TRD0365 REV D

MATRX® KID*AB*RA CUSHION: Pediatric – Skin Protection & Positioning Cushion

Kid*ab*ra Cushion 4 HCPCS Code: E2607

MODEL FITS WIDTH FITS DEPTH MSRPq KA1212‐Vi 11", 12" 12", 13" $425.00q KA1214‐Vi 11", 12" 14", 15" $425.00q KA1412‐Vi 13", 14" 12", 13" $425.00q KA1414‐Vi 13", 14" 14", 15" $425.00

Kid*ab*ra Extra Outer Cushion Cover (Refer to cushion sizes above for proper fit) 4 HCPCS Code: E2619

MODEL FITS WIDTH FITS DEPTH MSRPKC REFER TO CUSHION SIZES ABOVE $95.00

SPECIFY: WIDTH_____ DEPTH_____ q QTY____

MATRX® KID*AB*RA DROP BASE: Pediatric – Skin Protection & Positioning Cushion

Kid*ab*ra Drop Base Cushion 4 HCPCS Code: E2231

MODEL FITS WIDTH FITS DEPTH MSRPq KB1212‐Vi 12" 12", 13" $200.00q KB1214‐Vi 12" 14", 15" $200.00q KB1312‐Vi 13" 12", 13" $200.00q KB1314‐Vi 13" 14", 15" $200.00q KB1412‐Vi 14" 12", 13" $200.00q KB1414‐Vi 14" 14", 15" $200.00

DROP HOOKS MOUNTING SPECIFICATIONS:Diameter: q 7/8" q 1"Front Seat: q FLUSH q 1" q 2"Rear Seat: q FLUSH q 1" q 2"

Kid*ab*ra Drop Base Extra Outer Cover (Refer to drop base sizes above for proper fit)4 HCPCS Code: E2619

MODEL FITS WIDTH FITS DEPTH MSRPKBC REFER TO CUSHION SIZES ABOVE $90.00


n Weight capacity up to 150 lbsn Comes standard with inner cover and Kid*ab*ra

outer covers

n Weight capacity up to 150 lbsn Includes dropbase and mounting hardware

REAR

FRONT

DEPTH**

WIDTH* NOTE: Actual cushion width is ½" narrowerthan stated size and cushion depth is 1"longer than stated depth due to rear cushion radius.n Cushion modifications are available and

can be specified on Page 15

NOTE: Base can only be ordered with corresponding Kid*ab*ra Cushionn Must specify drop hook size: 7/8" or 1"

diameter and 1" or 2" drop

Kid*ab*ra Outer Cover

1"

INVACARE® MATRX® CUSHIONS – US PRICE LIST/ORDER FORM

1.888.433.6818 FAX: 1.888.433.6834 2 of 15 TRD0365 REV D



QUANTITY MODEL FITS WIDTH FITS DEPTH MSRPq QTY____ KA1212‐Vi 11", 12" 12", 13" $425.00q QTY____ KA1214‐Vi 11", 12" 14", 15" $425.00q QTY____ KA1412‐Vi 13", 14" 12", 13" $425.00q QTY____ KA1414‐Vi 13", 14" 14", 15" $425.00






QUANTITY MODEL FITS WIDTH FITS DEPTH MSRPq QTY____ KB1212‐Vi 12" 12", 13" $200.00q QTY____ KB1214‐Vi 12" 14", 15" $200.00q QTY____ KB1312‐Vi 13" 12", 13" $200.00q QTY____ KB1314‐Vi 13" 14", 15" $200.00q QTY____ KB1412‐Vi 14" 12", 13" $200.00q QTY____ KB1414‐Vi 14" 14", 15" $200.00






outer covers


REAR

FRONT

DEPTH**






9



1.888.433.6818 FAX: 1.888.433.6834 1 of 22 TRD0366 REV E

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________












1.888.433.6818 FAX: 1.888.433.6834 3 of 15 TRD0365 REV D

n Weight capacity up to 300 lbsn Comes standard with inner cover and outer

covers made of Meshtex material

n Startex fabric or smooth fabric side up, Onyxor Fusion Covers are available as an upcharge

REAR

FRONT

DEPTH**

WIDTH* NOTE: Actual cushion width is ½" narrowerthan stated size and cushion depth is 1½"longer than stated depth due to rear cushion radius.n Cushion modifications are available and

can be specified on Page 15MeshtexOuter Cover

MATRX® Vi CUSHION: Standard – Skin Protection & Positioning Cushion

Vi Cushion 4 HCPCS Code: E2607

MODEL FITS WIDTH FITS DEPTH MSRPq MA1415‐Vi 13", 14" 15", 16" $425.00q MA1417‐Vi 13", 14" 17", 18" $425.00q MA1616‐Vi 15", 16" 16", 17" $425.00q MA1618‐Vi 15", 16" 18", 19" $425.00q MA1620‐Vi 15", 16" 20", 21" $425.00q MA1716‐Vi 16", 17" 16", 17" $425.00q MA1718‐Vi 16", 17" 18", 19" $425.00q MA1720‐Vi 16", 17" 20", 21" $425.00q MA1816‐Vi 17", 18" 16", 17" $425.00q MA1818‐Vi 17", 18" 18", 19" $425.00q MA1820‐Vi 17", 18" 20", 21" $425.00q MA2016‐Vi 19", 20" 16", 17" $425.00q MA2018‐Vi 19", 20" 18", 19" $425.00q MA2020‐Vi 19", 20" 20", 21" $425.00

4 HCPCS Code: E2608

q MA2218‐Vi 21", 22" 18", 19" $475.00 q MA2220‐Vi 21", 22" 20", 21" $475.00

COVER OPTIONS: ADDSPECIFY: q STARTEX‐F (Startex Cover ‐ Fabric) q STARTEX‐S (Startex Cover‐Smooth) $50.00

q OCU‐MA (Onyx Cover) q FSU‐MA(Fusion Cover) $100.00

Vi Extra Outer Cushion Cover (Refer to cushion sizes above for proper fit) 4 HCPCS Code: E2619

MODEL FITS WIDTH FITS DEPTH MSRPC REFER TO CUSHION SIZES ABOVE $100.00


*C2218 &C2220 are $110.00

9



1.888.433.6818 FAX: 1.888.433.6834 1 of 22 TRD0366 REV E

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________












1.888.433.6818 FAX: 1.888.433.6834 4 of 15 TRD0365 REV D

MATRX® Vi DROP BASE: Standard – Skin Protection & Positioning Cushion

Vi Drop Base 4 HCPCS Code: E2231

MODEL FITS WIDTH FITS DEPTH MSRPq MB1415‐Vi 14" 15", 16" $200.00q MB1417‐Vi 14" 17", 18" $200.00q MB1516‐Vi 15" 16", 17" $200.00q MB1518‐Vi 15" 18", 19" $200.00q MB1616‐Vi 16" 16", 17" $200.00q MB1618‐Vi 16" 18", 19" $200.00q MB1716‐Vi 17" 16", 17" $200.00q MB1718‐Vi 17" 18", 19" $200.00q MB1816‐Vi 18" 16", 17" $200.00q MB1818‐Vi 18" 18", 19" $200.00q MB1916‐Vi 19" 16", 17" $200.00q MB1918‐Vi 19" 18", 19" $200.00q MB2016‐Vi 20" 16", 17" $200.00q MB2018‐Vi 20" 18", 19" $200.00


Vi Drop Base Extra Outer Cover (Refer to drop base sizes above for proper fit) 4 HCPCS Code: E2619

MODEL FITS WIDTH FITS DEPTH MSRPBC REFER TO DROP BASE SIZES ABOVE $90.00*



NOTE: Base can only be ordered with corresponding Matrx Cushionn Must specify drop hook size: 7/8" or 1"

diameter and flush 1" or 2" drop

MATRX® Vi CUSHION RIGIDIZER

Vi Cushion Rigidizer 4 HCPCS Code: E0992

MODEL FITS WIDTH FITS DEPTH MSRPq CR14S 12"‐14" 12"‐17" $75.00q CR16S 15", 16" 15", 16" $75.00q CR16M 15", 16" 17", 18" $75.00q CR16L 15", 16" 19", 20" $75.00q CR18S 17", 18" 15", 16" $75.00q CR18M 17", 18" 17", 18" $75.00q CR18L 17", 18" 19", 20" $75.00q CR20S 19", 20" 15", 16" $75.00q CR20M 19", 20" 17", 18" $75.00q CR20L 19", 20" 19",20" $75.00q CR22M 21", 22" 17", 18" $95.00q CR22L 21", 22" 19", 20" $95.00

n Recommended for chairs with sling seat upholstery.

NOTE: Lightweight plastic seat insert fits between seat rails for level support and eliminates hammock effect of seat upholstery.

REAR

FRONT

DEPTH**

WIDTH*


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QUANTITY MODEL FITS WIDTH FITS DEPTH MSRPq QTY____ KA1212‐Vi 11", 12" 12", 13" $425.00q QTY____ KA1214‐Vi 11", 12" 14", 15" $425.00q QTY____ KA1412‐Vi 13", 14" 12", 13" $425.00q QTY____ KA1414‐Vi 13", 14" 14", 15" $425.00






QUANTITY MODEL FITS WIDTH FITS DEPTH MSRPq QTY____ KB1212‐Vi 12" 12", 13" $200.00q QTY____ KB1214‐Vi 12" 14", 15" $200.00q QTY____ KB1312‐Vi 13" 12", 13" $200.00q QTY____ KB1314‐Vi 13" 14", 15" $200.00q QTY____ KB1412‐Vi 14" 12", 13" $200.00q QTY____ KB1414‐Vi 14" 14", 15" $200.00






outer covers


REAR

FRONT

DEPTH**






1"



1.888.433.6818 FAX: 1.888.433.6834 1 of 22 TRD0366 REV E

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________












1.888.433.6818 FAX: 1.888.433.6834 6 of 15 TRD0365 REV D

n Weight capacity up to 150 lbs n Comes standard with inner cover and reversible

Startex® outer covers

n No charge outer cover options: Kid*ab*ra, Pink Lollipop or Blizzard Blue (all non-reversible)

REAR

FRONT

DEPTH**


can be specified on Page 15 (cover will benon-reversible)

Startex Outer Cover


Pink LollipopOuter Cover

Blue BlizzardOuter Cover

MATRX® PS CUSHION: Pediatric Positioning Cushion

PS Cushion 4 HCPCS Code: E2605

MODEL FITS WIDTH FITS DEPTH MSRPq PS1010 9", 10" 10", 11" $345.00q PS1012 9", 10" 12", 13" $345.00q PS1014 9", 10" 14", 15" $345.00 q PS1212 11", 12" 12", 13" $345.00q PS1214 11", 12" 14", 15" $345.00q PS1216 11", 12" 16", 17" $345.00q PS1412 13", 14" 12", 13" $345.00q PS1414 13", 14" 14", 15" $345.00q PS1416 13", 14" 16", 17" $345.00

COVER OPTIONS:SPECIFY: q PS (Startex) q PS‐K (Kid*abra) q PS‐P (Pink Lollipop) q PS‐B (Blizzard Blue)

PS Extra Outer Cover (Refer to cushion sizes above for proper fit) 4 HCPCS Code: E2619

MODEL FITS WIDTH FITS DEPTH MSRPPSC REFER TO CUSHION SIZES ABOVE $85.00*


COVER OPTIONS:SPECIFY: q PSC (Startex) q PSC‐K (Kid*abra)

q PSC‐P (Pink Lollipop) q PSC‐B (Blizzard Blue)

9



1.888.433.6818 FAX: 1.888.433.6834 1 of 22 TRD0366 REV E

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________












1.888.433.6818 FAX: 1.888.433.6834 7 of 15 TRD0365 REV D

MATRX® PS CUSHION: Standard – Positioning Cushion

PS Cushion 4 HCPCS Code: E2605

MODEL FITS WIDTH FITS DEPTH MSRPq PS1616 15", 16" 16", 17" $345.00q PS1618 15", 16" 18", 19" $345.00q PS1620 15", 16" 20", 21" $345.00 q PS1816 17", 18" 16", 17" $345.00q PS1818 17", 18" 18", 19" $345.00q PS1820 17", 18" 20", 21" $345.00q PS2016 19", 20" 16", 17" $345.00q PS2018 19", 20" 18", 19" $345.00q PS2020 19", 20" 20", 21" $345.00

PS Extra Outer Cover (Refer to cushion sizes above for proper fit) 4 HCPCS Code: E2619

MODEL FITS WIDTH FITS DEPTH MSRPPSC REFER TO CUSHION SIZES ABOVE $85.00*


n Weight capacity up to 300 lbs n Comes standard with inner cover and reversible

Startex® outer cover

REAR

FRONT

DEPTH**


can be specified on Page 15 (cover will benon-reversible) Startex

Outer Cover

9



1.888.433.6818 FAX: 1.888.433.6834 1 of 22 TRD0366 REV E

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________












1.888.433.6818 FAX: 1.888.433.6834 9 of 15 TRD0365 REV D

n Weight capacity up to 300 lbsn Comes standard with foam base, fluid sac,

platilon inner liner and Startex® outer cover

n Spacetex is a no charge outer cover option; Infection Control additional $50 (all non-reversible)

StartexOuter Cover

NOTE: Actual cushion width is as statedand cushion depth is 1½" longer than stateddepth due to rear cushion radius.

REAR

FRONT

DEPTH**

WIDTH*

Spacetex Outer Cover

Infection ControlOuter Cover

Startex Outer Cover

Infection Control Outer Cover

Spacetex Outer Cover

MATRX® LIBRA CUSHION: Standard – Adjustable Skin Protection and Positioning Cushion

Libra Cushion 4 HCPCS Code: E2624

MODEL FITS WIDTH FITS DEPTH MSRPq LC1412 14" 12", 13" $485.00 q LC1414 14" 14", 15" $485.00 q LC1416 14" 16", 17" $485.00 q LC1516 15" 16", 17" $485.00 q LC1518 15" 18", 19" $485.00 q LC1520 15" 20", 21" $485.00 q LC1616 16" 16", 17" $485.00 q LC1618 16" 18", 19" $485.00 q LC1620 16" 20", 21" $485.00 q LC1622 16" 22", 23" $595.00 q LC1716 17" 16", 17" $485.00 q LC1718 17" 18", 19" $485.00 q LC1720 17" 20", 21" $485.00 q LC1722 17" 22", 23" $595.00 q LC1816 18" 16", 17" $485.00 q LC1818 18" 18", 19" $485.00 q LC1820 18" 20", 21" $485.00 q LC1822 18" 22", 23" $595.00 q LC1916 19" 16", 17" $485.00 q LC1918 19" 18", 19" $485.00 q LC1920 19" 20", 21" $485.00 q LC1922 19" 22", 23" $595.00 q LC2016 20" 16", 17" $485.00 q LC2018 20" 18", 19" $485.00 q LC2020 20" 20", 21" $485.00 q LC2022 20" 22", 23" $595.00

COVER OPTIONS:SPECIFY: q LC (Startex) q LC‐SP (Spacetex) q LC‐IC (Infection Control)*

*Additional $50 for Infection Control Cover

Libra Extra Outer Cover (Refer to cushion sizes above for proper fit) 4 HCPCS Code: E2619

MODEL FITS WIDTH FITS DEPTH MSRPLCC REFER TO CUSHION SIZES ABOVE $100.00LSC REFER TO CUSHION SIZES ABOVE $125.00LIC REFER TO CUSHION SIZES ABOVE $150.00


COVER OPTIONS:SPECIFY: q LCC (Startex)q LSC (Spacetex) q LIC (Infection Control)



1.888.433.6818 FAX: 1.888.433.6834 1 of 22 TRD0366 REV E

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________











INVACARE® MATRX® CUSHIONS – FREEDOM DESIGNS ON-CHAIR ORDER FORMINVACARE® MATRX® SEATING SERIES – US PRICE LIST

1.888.433.6818 FAX: 1.888.433.6834 11 of 15 TRD0365 REV D

MATRX® LIBRA FIT KIT COMPONENTS & OTHER COMPONENTS:

Libra ComponentsQUANTITY MODEL COMPONENT MSRPq QTY____ LAB Libra Abductor $60.00

1" Abductor built‐up ‐ Top mountedq QTY____ FTSW Anterior Seat Wedges $90.00

1" Anterior wedge increases pre‐ischial contour ‐ Underside mounted

q QTY____ FTHW Hemi Wedges $50.00 1" Anterior thigh support ‐ Underside mounted

q QTY____ FTTW‐LFRR Tapered Wedge LFRR $50.00 ¾" Tapered wedge for users’s Left front or Right rear ‐ Underside mounted

q QTY____ FTTW‐RFLR Tapered Wedge LFLR $50.00 ¾" Tapered wedge for users’s Right front or Left rear ‐ Underside mounted

q QTY____ LFS Libra Fluid Supplement $50.00 May be used to accommodate mild pelvic obliquity/additional pressure reduction

q QTY____ FTLW Lateral Wedge $65.00 1" Lateral wedge increases hip/thigh loading, ‐ Underside mounted

q QTY____ CLCFP‐M Complete Libra Cushion Fluid Sac $315.00 18" Wde and below

SPECIFY CUSHION SIZE: WIDTH_____ DEPTH_____

q QTY____ CLCFP‐L Complete Libra Cushion Fluid Sac $315.00 19" Wde and above

SPECIFY CUSHION SIZE: WIDTH_____ DEPTH_____

q QTY____ LCPL‐WWDD Platilon Inner Liner $35.00 SPECIFY CUSHION SIZE: WIDTH_____ DEPTH_____



1.888.433.6818 FAX: 1.888.433.6834 1 of 22 TRD0366 REV E

Date of Order:______________________________________________

Dealer Name: ______________________________________________

Dealer Account #: __________________________________________

PO #: ____________________________________________________

Tag: ______________________________________________________


Phone: ____________________Fax: ____________________________

Ship to Address: ____________________________________________

__________________________________________________________

City: ______________________________________________________

State:____________________Zip: ______________________________

Comments: ________________________________________________

__________________________________________________________

__________________________________________________________












REAR

FRONT

DEPTH**

WIDTH*

LEFT SIDE RIGHT SIDE

SEAT WITDTH REDUCTION

SEAT DEPTHREDUCTION

LEG LENGTHDISCREPENCY

NOTE: Rear Cushion radius included on all PS, VI & Libra Cushions.

Notes:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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1.888.433.6818 FAX: 1.888.433.6834 15 of 15 TRD0365 REV D

CUSHION MODIFICATIONS:

Modifications (Additional one week lead time)QUANTITY MODEL COMPONENT MSRPq QTY____ SDR Seat Depth Reduction $100.00

Less: q 1" q 2"* q 3"* q 4"* Specify_____*Not available on Libra Cushions

q QTY____ SWR Seat Width Reduction $100.00Less: q 1" q 2"* q 3"* q 4"* Specify_____

*Not available on Libra Cushions

q QTY____ LLDR Leg Length Discrepancy ‐ Right $100.00Less: q 1" q 2" Specify_____

q QTY____ LLDL Leg Length Discrepancy ‐ Left $100.00Less: q 1" q 2" Specify_____

q QTY____ ECM Outer Cover Modification $50.00 Accommodates LLDL/LLDR/SDR/SWR

q QTY____ MAC Miscellaneous Modification $100.00 Please use a diagram above to indicate required modifications‐ Requires approval

ACCESSORIES & HARDWARE:QUANTITY MODEL COMPONENT MSRPq QTY____ CIC Extra Inner Cover $75.00

1" Pelvic Obliquity built‐up‐ Top mountedq QTY____ NSF Non‐Standard Fabric Selection $75.00

Available for Cushions/bases; excluding Flo‐tech & Libraq QTY____ POK Pelvic Obliquity Kit $50.00

Accommodates ½” and ” Obliquitiesq QTY____ BDH0 Base Drop Hooks (pair) $27.00

Flushmount (0) drop for 7/8” or 1” Diameterq QTY____ BDH1‐7/8 Base Drop Hooks (pair) $27.00

1” Drop for 7/8” Diameterq QTY____ BDH2‐7/8 Base Drop Hooks (pair) $27.00

2” Drop for 7/8” Diameterq QTY____ BDH1‐1 Base Drop Hooks (pair) $27.00

1” Drop for 1” Diameterq QTY____ BDH2‐1 Base Drop Hooks (pair) $27.00

1” Drop for 2” Diameterq QTY____ BDC Dura Clip (pair) $60.00

Top lock retractable hardware for use with Drop Hooksq QTY____ BFC FixClip (pair) $25.00

Top lock hardware for use with Drop Hooks


REAR

FRONT

DEPTH**

WIDTH*



SEAT DEPTHREDUCTION



Notes:

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________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

1.888.433.6818 FAX: 1.888.433.6834 15 of 15 TRD0365 REV D






















REAR

FRONT

DEPTH**

WIDTH*



SEAT DEPTHREDUCTION



Notes:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

1.888.433.6818 FAX: 1.888.433.6834 15 of 15 TRD0365 REV D






















REAR

FRONT

DEPTH**

WIDTH*



SEAT DEPTHREDUCTION



Notes:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

1.888.433.6818 FAX: 1.888.433.6834 15 of 15 TRD0365 REV D





















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