m300 corpus hd - permobilcountries.permobil.com/global/usa/order forms/us-m300-corpu… · m300...

Three column pricing on order/quote:

PO#:______________________________

* Dealer Name:______________________________

Address:______________________________

* Phone#:______________________________

* Contact:______________________________

* City:______________________________

* Fax#:______________________________

* Weight:_______________________________

*Height:_______________________________

A) Top of Shoulders:_______________________________

B) Chest Depth:_______________________________

C) Chest Width:_______________________________

D) Seat Depth:_______________________________

E) Top of Head:_______________________________

F) Elbow to Hand:_______________________________

G) Seat Pan to Elbow:_______________________________

H) Hip Width:_______________________________

*I) Knee to Foot:_______________________________

Permobil Inc.300 Duke Dr.

Lebanon, TN 37090Tel: (800) 736-0925Fax: (800) 231-3256

www.permobil.com

* State/Zip:______________________________

Diagnosis:______________________________

Permobil recommends that the client is evaluated by a certified rehab specialist.

Dealer Information

Client Information

Client Measurements

Funding Source:______________________________

Prices effective March 1, 2013

Client Age:______________________________

Dealer Code:______________________________

* First Name:______________________________

* Indicates a Required Field

* Last Name:______________________________

Email Address:______________________________

Display HCPCS Codes on order/quote:

Please send order/quote to fax#: (800) 231-3256 Email to: [email protected]

M300 Corpus HD

M300 Corpus HD

Chair Model and Colors

CHOOSE BASE:Part Number Description Price HCPCS Code

I10908 M300 Base Corpus HD - SPO 8,945.00 K0858Price Includes: M300 Power HD Base Set Up For One Power Seat Function, Shock Absorbing Suspension System, R-net Controller, Tie-Down Hardware For Strap Systems, Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below. 5.0mph, Weight Capacity = 450lbs.

I105799-99-0 M300 Base Corpus HD - MPO 8,945.00 K0862Price Includes: M300 HD Power Base Set Up For Multiple Power Seat Functions, Shock Absorbing Suspension System, R-net Controller, Tie-Down Hardware For Strap Systems, Charger, Flat Free Tires, and Standard Positioning Belt. Must Choose Flat Free or Pneumatic Tires Below. 5.0mph, Weight Capacity = 450lbs.

CHOOSE DRIVE TIRES:Part Number Description Price HCPCS Code

I103499-99-0 Tri-Spoke Split Rim w/ Flat Free Drive Tire 3x8" No Charge

I103498-99-0 Tri-Spoke Split Rim w/ Pneumatic Tires - 3x8" No ChargeOPTIONAL DRIVE TIRES:

Part Number Description Price HCPCS Code

I10782 Tri-Spoke Split Rim w/ Snow Tire Pneumatic 3x8" 407.00Snow tires are designed for use in cold weather conditions. The nylon compound in these tires remains flexible at low temperatures, but wears more easily. Therefore, the snow tires (sold as wheel assemblies) are not recommended for year-long use and must be ordered along with standard drive wheels.

CHOOSE SHROUD COLOR:Part Number Description Price HCPCS Code

I105885-99-0 M300 HD Shroud - Onyx Black No Charge

I105881-99-0 M300 HD Shroud - Platinum Silver No Charge

I105887-99-0 M300 HD Shroud - Sublime Green No Charge

I106169-99-0 M300 HD Shroud - Cobalt Blue No Charge

I106171-99-0 M300 HD Shroud - Phantom Grey No Charge

I106159-99-0 M300 HD Shroud - Pop Star Pink No Charge

I106170-99-0 M300 HD Shroud - Purple Rain No Charge

I106160-99-0 M300 HD Shroud - Volcano Red No Charge

I106216-99-0 M300 HD Shroud - Digital Army Camo (UCP) 225.00Hydrographic processing used to apply design. Includes no-gloss clear coat.

I106217-99-0 M300 HD Shroud - MultiCam Camo 225.00Hydrographic processing used to apply design. Includes no-gloss clear coat.

I106218-99-0 M300 HD Shroud - Realtree AP Camo 225.00Hydrographic processing used to apply design. Includes no-gloss clear coat.

CHOOSE HUBCAP COLOR:Part Number Description Price HCPCS Code

Match Hub Cap Color to Shroud: _____Note: Hub caps will be matched to shroud color/decoration if no selection is made. Matched hub caps carry the prices listed below.

I10871 Solid Color Hub Caps - Pair No ChargePlatinum Silver: _____ Onyx Black: _____ Cobalt Blue: _____ Phantom Gray: _____ Pop Star Pink: _____ Volcano Red: _____ Purple Rain: _____ Titan Blue: _____ Sublime Green: _____ Crystal Blue: _____ Vintage Wine: _____ Extreme Yellow: _____ Chili Pepper Red: _____ Green Metallic: _____

I10872 Decorated Hub Caps - Pair 50.00Digital Army Camo: _____ MultiCam Camo: _____ RealTree AP Camo: _____

Base Options

MUST CHOOSE EITHER SEAT ELEVATOR OR FIXED SEAT TUBE:Part Number Description Price HCPCS Code

I105875-99-0 HD Power Adjustable Seat Height - 8" Travel 2,895.00 E2300

I105880-99-0 HD Seat Tube Fixed No Charge

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Base Options

MUST CHOOSE BATTERIES:Part Number Description Price HCPCS Code

IM24 SLD G FT Batteries, Grp 24 (72Ah) Sealed LA/Gel, Installed 824.00 E2363

IM34 SLDG Batteries, Grp 34 (60Ah) Sealed LA/Gel, Installed 814.00 E2359CHOOSE SEAT PAN TO FLOOR HEIGHT:


I105878-99-0 Set Seat to Floor Height at 18" No Charge

I105877-99-0 Set Seat to Floor Height at 19" No Charge

I105876-99-0 Set Seat to Floor Height at 20" No ChargeOPTIONAL ITEMS:


I105428-99-0 Enhanced Steering Perform Unit (ESP), R-net 1,205.00 K0108Recommended item with switched drive inputs for improved tracking.

I105297-99-0 LED Light Kit for M300 / M400 w/ R-net Electronics 995.00

I10715 Compact Laptop Ventilator Tray - Corpus 3G Seat 1,385.00Mounts to rear of Corpus 3G backrest hinge. Accommodates Pulmonetic Systems / CareFusion LTV Series and similar sized Laptop Ventilators. The tray is 13"T, adjustable in width from 8" - 13", and adjustable in depth from 2" - 6.5". Overall backrest angle limited to 150° when mounting this ventilator tray. Custom Option.

I10787 Battery Tray for Laptop Ventilator Tray 208.00 K0108Measures 11 3/8" W x 6 1/2" H x 1 5/8" D. Accomodates Pulmonetic Systems Lithium-Ion Battery Pack, CareFusion SprintPack Battery System, or Richardson PowerTech Vent Power Center. Custom Option.

I10788 O2 Holder for Laptop Ventilator Tray 295.00 K0108Mounts to Left or Right Side of Laptop Vent Tray. O2 Holder is 7" Tall. Width infinitely adjustable 3.5" - 7". Depth infinitely adjustable 3.75" - 5". Custom Option.

ID51113 Programming Key for R-net - Permobil Version 456.00

Joystick Options

CHOOSE JOYSTICK TYPE:Part Number Description Price HCPCS Code

PLEASE NOTE: For additional input devices, refer to Alterative Drive Systems Section.

I105246-99-0 R-net LED Remote Joystick Module No ChargeStandard Joystick Module. This Joystick does NOT have an LCD Display and does NOT contain mono jacks. Limited to five profiles with this Joystick Module.

I10746 R-net Remote Color JS w/ Mono Jacks, No Lights, NC No Charge

ID51185 R-net Remote Color JS w/ Mono Jacks, No Lights 716.00

ID51188 R-net Remote Color JS w/ Toggle Switches, No Lghts 917.00

I10747 R-net Remote Color JS w/ Mono Jacks, Lights, NC No Charge

ID51153 R-net Remote Color JS w/ Mono Jacks, Lights 716.00

ID51149 R-net Remote Color JS w/ Toggle Switches, Lights 917.00

ID51190 R-net Remote Color JS w/ Spd Pot/Toggle, Lights 917.00

I105700-99-0 R-net Remote Color JS w/ Lights, Heavy Duty Gimble 972.00Heavy-Duty modification enables gimble to hold up to extreme operating forces. Reinforced housing is attached to a standard Color LCD R-net Joystick. 3" long joystick knob has 3/4" diameter. Not compatible with alternative joystick handles.

I103814-99-0 Compact Advanced Joystick for R-net 634.00 E2373Compact sized joystick that does not contain an LCD Display. Must order expandable controller (PN: I10411) with this part. Contains two mono jacks for mode & on/off. Does NOT contain a wrist support pad. If you want a wrist support pad, please select I10621, below.

I10621 Add Wrist Pad to Compact Joystick Advanced 204.00CHOOSE JOYSTICK HANDLE TYPE:


I10045 Cone Shaped Joystick Knob - Standard No Charge

I100960-99-0 Chin Cup For Joystick Knob 99.00 E2324

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Joystick Options

CHOOSE JOYSTICK HANDLE TYPE:Part Number Description Price HCPCS Code

I100961-99-0 "T" Handle For Joystick Knob 145.00 E2323

I100962-99-0 "Large Ball" For Joystick Knob 99.00 E2323

I100963-99-0 "Softball" For Joystick Knob 133.00 E2323

I100964-99-0 "Mushroom" For Joystick Knob 133.00 E2323

I100965-99-0 "Stick" For Joystick Knob 133.00 E2323

I105442-99-0 1.75" Black Foam Ball For Joystick Knob 99.00 E2323

IPC101B Bodypoint J/S Handle 3" U-Shaped w/ Flex-Shaft 133.00 E2323

IPC102B Bodypoint J/S Handle 4" U-Shaped w/ Flex-Shaft 133.00 E2323

IPC107B Bodypoint J/S Handle Dome Shaped, Rubber 133.00 E2323CHOOSE JOYSTICK MOUNT:


I10664 Joystick Mount Right - Fixed No Charge

I10665 Joystick Mount Left - Fixed No Charge

I102537-99-0 Joystick Mount Right - Swing Away, R-net & VR2 306.00 E1028

I102538-99-0 Joystick Mount Left - Swing Away, R-net & VR2 306.00 E1028

I103820-99-0 Retractable Joystick Mnt Right - R-net, VR2 510.00 E1028

I103819-99-0 Retractable Joystick Mnt Left - R-net, VR2 510.00 E1028

I105210-99-0 Mount Standard Joystick on Corpus 3G Back Hinge 243.00Standard R-net Joystick is mounted to backrest hinge. Can be chosen instead of PN I105408-99-0. Mount on Left: _____ Mount on Right: _____

I101260-99-0 Midline Control Mount - Pilot+ & R-net 276.00 E1028Mount Midline on Left Armrest: _____ Mount Midline on Right Armrest: _____

I10793 Stealth Gatlin Mid Line Mount - 8 Position 535.00 E1028Features eight locking positions each 45° apart. Adjustments are made by pulling out on mounting arm and rotating to desired angle. Joystick bracket sold separately (select from the brackets listed below). Please indicate if you want it mounted on left or right armrest: Mount Midline on Left Armrest: _____ Mount Midline on Right Armrest: _____

I10794 Stealth Gatlin Mid Line Mount - 2 Position 535.00 E1028Designed for easy swing away. Mount can be set to swing from horizontal to 95° or from horizontal to 180°. Joystick bracket sold separately (select from the brackets listed below). Please indicate if you want it mounted on left or right armrest: Mount Midline on Left Armrest: _____ Mount Midline on Right Armrest: _____

I10803 Stealth Gatlin Bracket for R-net/Compact JS Adv 220.00 E1028

I10804 Stealth Gatlin Bracket for Compact Joystick 220.00 E1028

I10805 Stealth Gatlin Bracket for Mini-Joystick 220.00 E1028

I10806 Stealth Gatlin Swivel Bracket for Omni 250.00 E1028

I10842 PERMOFix Joint for Gatlin (0027-7027a) 220.00 E1028Includes a shim washer that allows the PermoFix joint to be mounted on the 1/2" Stealth Gatlin arm. Provides an adjustable mount for a Mini Joystick or Compact Joystick.

I10802 Stealth Height Adjustable Mnt (ARM250-P) 195.00 E1028Replaces standard UT panel bracket. Provides 1.75" of height adjustability to all Permobil joystick mounts and Stealth Gatlin Mid Line mounts.

OPTIONAL ITEMS:Part Number Description Price HCPCS Code

I10411 Expandable Controller - R-net 561.00 E2377This item is required when ordering power tilt, power recline, and power elevating legrests together OR when ordering an Alternative Drive Control.

I10513 Harness for Expandable Controller 489.00 E2313Must be ordered with any Expandable Controller (I10411 or I10450).

I105225-99-0 Co-Pilot Attendant Control R-net - Corpus 3G 4,375.00 E2331

I105408-99-0 Attendant Control R-net - Corpus 3G 1,136.00 E2331

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Joystick Options


I106057-99-0 R-net BT Mouse Module w/ Two Switch Adapters 833.00The R-net BT Mouse Module enables mouse control through any R-net Input Device (ex. Standard JSM, Mini-JS w/ Omni, etc). It can only operate the mouse on a computer. It CANNOT be paired to work with other Bluetooth devices such as cell phones, wireless headsets, etc. This kit includes: a R-net BT Mouse Module, a 1.5m R-net Bus Cable, two monojack cables for L/R click (switches not included), & a USB BT Adapter for the user's computer. Note: The BT Adapter may not work with all computers.

I10582 Output Module (IOM) for R-net Control System 1,042.00 E2351,K0108This allows a user to control an external device (ex: Communication Device, ECU, Door Opener, etc.) through the drive input (JSM, Head Array, etc.). One output module is required for each separate external device to be controlled. Up to three output modules can be installed on one wheelchair.

Seating System

CHOOSE SEATING SYSTEM:Part Number Description Price HCPCS Code

PLEASE NOTE: Weight Limit 450lbs. For the Corpus HD Seat on the M300, there is a half speed drive limit when the Total Backrest Angle (TBA) > 135° and a drive inhibit at 150° of TBA. There is also adrive inhibit at 20° of tilt.

I10910 HD Seat w/ No Tilt & Manual Recline 6,595.00 K0108Manual Recline angle limited to 120°.

I10911 HD Seat w/ No Tilt & 150° Power Recline 7,450.00 E1004

I10912 HD Seat w/ 45° DuraCore Tilt & Manual Recline 7,195.00 E1002Manual Recline angle limited to 120°.

I10913 HD Seat w/ 45° DuraCore Tilt & 150° Power Recline 11,295.00 E1007

Seating System Options

CHOOSE SEAT FUNCTION CONTROL TYPE:Part Number Description Price HCPCS Code

I10418 Single Seat Function Control Switch for R-net No ChargePlease choose either Push Buttons or Toggle Switches below.

I10419 Single Seat Function Control Kit for R-net 1,540.00 E2310For operation of a single seat function through the wheelchair electronics via the drive control and/or ICS Switchbox. Order with R-net Controller or remote joystick options. Please indicate below if you want push buttons or toggles on the ICS Switchbox.

I10585 Multiple Seat Function Control Kit for R-net 3,013.00 E2311MUST be selected if ordering two or more seat functions. This device is used to operate two or more seat functions through the wheelchair electronics via the drive control and/or ICS switch box. Order with R-net electronics or remote joystick options. Please indicate below if you want push buttons or toggles on the ICS Switchbox.

CHOOSE PUSH BUTTONS OR TOGGLES:Part Number Description Price HCPCS Code

I102798-99-0 Push Buttons on ICS Switchbox No Charge

I102799-99-0 Toggle Switches on ICS Switchbox 256.00

I105409-99-0 Do Not Install ICS Switchbox, Send as Part No ChargeCHOOSE MOUNTING POSITION OF ICS SWITCHBOX:


I10626 Mount ICS Switchbox onto R-net Joystick Bracket No ChargeICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this item is selected, the ICS Switchbox will swing away with the Joystick Module.

I104651-99-0 Mount ICS Switchbox onto Armr- Corpus 3G,K450,PSJR No ChargeMount on Left: _____ Mount on Right: _____

I103470-99-0 Mount ICS Switchbox on Backrest 131.00Mount on Left: _____ Mount on Right: _____

OPTIONAL ITEMS:

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Seating System Options


I104196-99-0 ICS Alternative Switchbox for R-net Electronics 1,032.00 K0108Not available with VR2 Electronics. Seat function interface box which accommodates up to 8 momentary switches. Provides an additional method to accessing the seat functions. You must still order the Multiple Seat Function Control Kit if ordering this part. 1/8" mini-mono switches not included.

I104769-99-0 Remote Stop System - All Electronics 1,032.00Consists of a Radio Frequency (RF) handheld transmitter and an RF receiver mounted on the wheelchair. Each transmitter and receiver is a serialized matched pair, meaning they must be used together. Custom charge may be required if ordering with a low backrest height or a pediatric wheelchair. If ordering Remote Stop System with a K450, push handles must also be selected.

I10750 Memory Seat Program, Corpus 3G w R-net 103.00

I10888 Legrest Movement Linked to Recline Electronically 39.00Power Legrest will raise when Power Recline moves backward and will lower when back moves forward. If Power Legrest is operated, Power Recline will NOT automatically reposition. Feature works through ICS Switchbox and Driver Control.

I10898 Enable Independent Repositioning Mode No ChargeEnables the Corpus 3G Independent Repositioning Mode through all Driver Control Input Devices. If a Switchbox Layout with memory is chosen, IRM will be accessible through the ICS Switchbox.

Backrest Options

CHOOSE FIXED OR SLIDING BACKREST KIT:Part Number Description Price HCPCS Code

I105871-99-0 Sliding Backrest Kit - 5" Mechanical Shear No Charge

I105869-99-0 Fixed Backrest Kit - No Mechanical Shear 30.00CHOOSE BACKREST TYPE:


BACKREST HEIGHT NOTE: Backrest heights are measured from the seat pan to the top of the backrest shell with the backrest set at 90°.

I106016-99-0 Corpus HD Ergo Backrest - 20"W x 21"T (C3GERGBCA) 898.00 E2620

I106017-99-0 Corpus HD Ergo Backrest - 22"W x 21"T 898.00

I106018-99-0 Corpus HD Ergo Backrest - 24"W x 21"T 898.00

I10915 Solid Back 20"W X 21"T - Corpus HD Seat No Charge

I10916 Solid Back 22"W x 21"T - Corpus HD Seat No Charge

I10917 Solid Back 24"W x 21"T - Corpus HD Seat No ChargePLEASE NOTE:

All taller backrests listed below include: lumbar pad, a UT rail mounted at the top for lateral adjustment of the headrest, and split backrest feature with height adjustment in 1" increments. Please indicate below where you want the height set at so that a properly sized backrest cushion can be provided.

I106019-99-0 Corpus HD Ergo Back -20"W x 24 - 29"T (C3GERGBCA) 898.00 E2620

I106020-99-0 Corpus HD Ergo Back -22"W x 24 - 29"T 898.00

I106021-99-0 Corpus HD Ergo Back -24"W x 24 - 29"T 898.00

I10919 Solid Back 20"W x 24 - 29"T - Corpus HD Seat No Charge

I10920 Solid Back 22"W x 24 - 29"T - Corpus HD Seat No Charge

I10921 Solid Back 24"W x 24 - 29"T - Corpus HD Seat No Charge Set Backrest at 24" _____ Set Backrest at 25" _____ Set Backrest at 26" _____ Set Backrest at 27" _____ Set Backrest at 28" _____ Set Backrest at 29" _____

CHOOSE BACKREST CUSHION:

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Backrest Options

CHOOSE BACKREST CUSHION:Part Number Description Price HCPCS Code

I10659 Leatherette Cushion - Corpus 3G Ergo Back No Charge

I10660 Black Mesh Cushion - Corpus 3G Ergo Back 30.00

I105117-99-0 Omit Backrest Cushion No ChargeOPTIONAL ITEMS:


I10725 Split Backrest Cushion - Corpus 3G 283.00Custom Option.

Seat Sizing

CHOOSE SEAT WIDTH SETTING:Part Number Description Price HCPCS Code

I105859-99-0 Set Seat Width at 19" No Charge



I105862-99-0 Set Seat Width at 25" No ChargeCHOOSE SEAT DEPTH:


PLEASE NOTE: Odd numbered seat depths can be made 1" shorter without any additional parts. For example, a 21"D Seat can also be set at 20"D.

I105863-99-0 Corpus HD Seat Depth 19" No Charge






I105857-99-0 Corpus HD Seat Depth 25" No ChargeCHOOSE SEAT CUSHION:


I10651 Corpus 3G Ergo Seat Cush - Leatherette (C3GERGSCA) 497.00 E2605

I10652 Corpus 3G Ergo Seat Cush - Black Mesh (C3GERGSCA) 508.00 E2605

I105118-99-0 Omit Seat Cushion No Charge

Armrest Options

CHOOSE ARMBAR MOUNTING POSITION:Part Number Description Price HCPCS Code

I106022-99-0 Set Armbar at 20"W Between Armrests:____ No Charge





I106027-99-0 Set Armbar at 25"W Between Armrests:____ No ChargeCHOOSE ARMREST HEIGHT MOUNTING POSITION:


I10923 Height Adjustable Armrests 315.00

I10924 Height Adjustable Armrests - NC No ChargeNo charge when ordering power tilt and/or recline.

SET ARMREST HEIGHT AT:____Corpus HD Armrests are infinitely adjustable from 8" - 16", measured from the seat pan to the top of the arrmrest pad. No additional parts are needed to get this full range of adjustment. In one inch increments (ex: 8", 9", etc.), please indicate where you would like the armrests set.

CHOOSE ARMREST PAD RIGHT:

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Armrest Options

CHOOSE ARMREST PAD RIGHT:Part Number Description Price HCPCS Code

I105104-99-0 4"x13" Corpus 3G Armrest Pad Right - Leatherette No Charge

I105997-99-0 4"x16" Corpus HD Armrest Pad Right - Leatherette No Charge

I105999-99-0 4"x18" Corpus HD Armrest Pad Right - Leatherette No Charge

I106047-99-0 4"x13" Corpus HD Armrest Pad Right - Black Fabric No Charge



I10927 4"x13" Corpus HD Arm w/ Stealth Gel Pad - Right 149.00

I10928 4"x16" Corpus HD Arm w/ Stealth Gel Pad - Right 149.00CHOOSE ARMREST PAD LEFT:


I105102-99-0 4"x13" Corpus 3G Armrest Pad Left - Leatherette No Charge

I105996-99-0 4"x16" Corpus HD Armrest Pad Left - Leatherette No Charge

I105998-99-0 4"x18" Corpus HD Armrest Pad Left - Leatherette No Charge

I106046-99-0 4"x13" Corpus HD Armrest Pad Left - Black Fabric No Charge



I10929 4"x13" Corpus HD Arm w/ Stealth Gel Pad - Left 149.00

I10930 4"x16" Corpus HD Arm w/ Stealth Gel Pad - Left 149.00OPTIONAL ITEMS:


I105463-99-0 Corpus 3G Arm Trough Adapter 1" - Pair 287.00For aftermarket armrest pads. Please indicate below if they should be installed or on chair sent as parts.

I105462-99-0 Corpus 3G Arm Trough Adapter 7/8" - Pair 287.00For aftermarket armrest pads. Please indicate below if they should be installed or on chair sent as parts.

Install Arm Trough Adapters: _____Send Arm Trough Adapters as Parts: _____

I100671-99-0 Armrest Pouch-Right 199.00

I100672-99-0 Armrest Pouch-Left 199.00

I10705 Corpus 3G Armrest Side Support - Right Outer 221.00Custom Option. Leatherette Pad (2"T x 8.5"L). Not compatible with Stealth Elbow Support, except when ordered with an 18" armrest.

I10706 Corpus 3G Armrest Side Support - Left Outer 221.00Custom Option. Leatherette Pad (2"T x 8.5"L). Not compatible with Stealth Elbow Support, except when ordered with an 18" armrest.

I10707 Corpus 3G Armrest Side Support - Right Inner 221.00Custom Option. Leatherette Pad (2"T x 8.5"L). Recommend 2" wider width between the armrest to ensure armrests will flip-up.

I10708 Corpus 3G Armrest Side Support - Left Inner 221.00Custom Option. Leatherette Pad (2"T x 8.5"L). Recommend 2" wider width between the armrest to ensure armrests will flip-up.

I106264-99-0 Stealth 3" x 10" Elbow Support, 3G/HD - Right 130.00 K0108Must also select PN I10881.

I106263-99-0 Stealth 3" x 10" Elbow Support, 3G/HD - Left 130.00 K0108Must also select PN I10882.

I10881 Adjustable Elbow Support Hardware - Right 220.00 E1028

I10882 Adjustable Elbow Support Hardware - Left 220.00 E1028

Legrest Options

CHOOSE LEGREST TYPE:Part Number Description Price HCPCS Code

I106053-99-0 Corpus HD Manual Adj Legrest Elevation No Charge

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Legrest Options

CHOOSE LEGREST TYPE:Part Number Description Price HCPCS Code

I106052-99-0 Power Elevating Center Mount Legrests - 175° 3,295.00 K0108Includes mechanical articulation.

CHOOSE FOOTPLATE STYLE:Part Number Description Price HCPCS Code

I106008-99-0 2pc Wide Corpus HD Footplates - 9"D x 7.5"W No Charge

I106009-99-0 2pc Extra Wide Corpus HD Footplates - 9"D x 9"W 221.00FOOTPLATE HEIGHT POSITION:


SET FOOTPLATE HEIGHT AT:____This is measured from the SEAT PAN to the top of the FOOTPLATE, when the legrest assembly is at 90° DO NOT INCLUDE CUSHION THICKNESS IN YOUR MEASUREMENT. In one inch increments, please indicate desired footplate height. NOTE: Standard Corpus HD footplate height range is 6" - 18". Calf Pads are not available at heights less than 10".

CHOOSE LATERAL FOOTPLATE ROTATION OPTIONS:Part Number Description Price HCPCS Code

I106006-99-0 Lateral Footplate Rotation - Fixed No Charge

I106007-99-0 Lateral Footplate Rotation - Enabled 29.00OPTIONAL ITEMS:


I106190-99-0 UT Calf Support Kit (A) w Mesh Cover & Adj Hardware No Charge5.5"W x 6"T Pad. Compatible with footplate heights of 10" - 18".

I106188-99-0 UT Calf Support Kit (H) w Mesh Cover & Adj Hardware 327.007"W x 7"T Curved Pad. Compatible with footplate heights of 11" - 18".

I106186-99-0 UT Calf Support Kit (D) w Mesh Cover & Adj Hardware 327.008"W x 8"T Pad. Compatible with footplate heights of 12" - 18".

I106225-99-0 Stealth Gel Pads - Wide Footplates (Pair) 275.00

I106224-99-0 Stealth Gel Pads - Extra Wide Footplates (Pair) 295.00

Accessories

MUST CHOOSE POSITIONING BELT:Part Number Description Price HCPCS Code

I10400 Bodypoint Non-Padded Hip Belt, UniTrack - Medium No Charge

I10404 Bodypoint Padded Hip Belt UniTrack - Medium 118.00 E0978

I100519-99-0 Positioning Belt Retractable 246.00 K0108

I10940 Bodypoint Non-Padded Hip Belt, UniTrack - Large No Charge

I10408 Bodypoint Padded Hip Belt UniTrack - Large 163.00 E0978

I10935 Bodypoint Padded Hip Belt UniTrack - Extra Large 208.00 E0978

I100600-99-0 Positioning Belt Retractable Long 267.00 K0108OPTIONAL ITEMS:


I105291-99-0 Headrest Corpus 3G Back, 10"W x 5"T, Leatherette 286.00 E0955Must also select PN I10552.

I105290-99-0 Headrest Corpus 3G Back, 10"W x 5"T, Black Fabric 306.00 E0955Must also select PN I10552.

I105212-99-0 Headrest Corpus 3G Back, Ergo Shape, Black Fabric 306.00 E0955Must also select PN I10552.

I10180 Universal Headrest Adapter 211.00 K0108Will be sent as part if ordering sling back upholstery.

I10552 Adj Removable - Headrest Hardware (1 Each) 222.00 E1028

I103070-99-0 UT Amp. Support Pad (H) w/ Mesh Cover - (1 Each) 131.00 E10207"W x 7"T Curved Pad. Must also select PN I10553.

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Accessories


I103071-99-0 UT Amp. Support Pad (D) w/ Mesh Cover - (1 Each) 131.00 E10208"W x 8"T Flat Pad. Must also select PN I10553.

I10553 Adj Removable - Amp Support Hardware (1 Each) 222.00 E1028Please indicate if you would like the amputation support mounted on the right or left side of the seat frame: Mount Amp Suppt on Left: ____ Mount Amp Suppt on Right: ____

I106104-99-0 UT Hip Suppt (B) w/ Mesh Cover - High (Pair) 236.00 E09564.5"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

I106103-99-0 UT Hip Suppt (A) w/ Mesh Cover - High (Pair) 236.00 E09566"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

I103094-99-0 UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair) 236.00 E09566.5"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

I103095-99-0 UT Thigh/Hip Suppt (C) w/ Mesh Cover - High (Pair) 236.00 E09568"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

I102977-99-0 UT Thigh/Hip Suppt (G) w/ Mesh Cover - High (Pair) 236.00 E095612"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

I10550 Adj Removable - Thigh Support Hardware (Pair) 444.00 E1028

I100978-99-0 Abductor Kit - Leatherette 320.00 E0957Must also select PN I10555.

I10555 Adj Removable - Abductor Hardware (1 Each) 222.00 E1028

I10783 Hand Heater Kit with Buddy Button 822.00Kit includes Hand Heater (2"H x 1.5"W x 2.75"D), Buddy Button, Power Cable with XLR Plug and PERMOfix Mounting Adapter. Heater has three temp/fan speed settings. For best results, a hand cone (I10784 or I10785) is recommended to trap heat around the user's hand(s). To ensure best positioning for the user, heater will NOT be mounted when chair is received.

I10784 One-Hand Cone Kit with PERMOfix Mounting Set 507.00Clear plastic dome (5.5"W x 13.5"L x 8"H) with forearm opening at one end. Kit includes PERMOfix mounting hardware to attach cone to end of armrest. To ensure best positioning for the user, cone will NOT be mounted when wheelchair is received.

I10785 Two-Hand Cone Kit with Mounting Pins 399.00Clear plastic triangular dome (15"W x 12.5"L x 8"H) with two forearm openings. Use with Upper Extremity Support is recommended. Kit includes four pins to secure cone to tray surface. Pins remove without tools for easy transfers. To ensure the best positioning for the user, cone will NOT be mounted.

I105260-99-0 Transfer Handles, Corpus 3G Seat 409.00

I105292-99-0 Push Handles, Corpus 3G Seat 355.00

I103044-99-0 Cup/Cell Phone Holder 47.00

I106210-99-0 Self-Leveling Cup Holder 67.00

I105563-99-0 Medical Necessities Bag Hooks - UniTrack 78.00

I102059-99-0 Medical Necessities Bag CII,VS,PS,C3G,CORPUS HD 236.00Includes hardware to attach bag to backrest.

I105144-99-0 Bodypoint Monoflex Large Chest Support Belt Kit 149.00 E096021.5"L x 4.5"W Pad Size. Item will be shipped as parts.

I105143-99-0 Bodypoint Monoflex Medium Chest Support Belt Kit 149.00 E096018.25"L x 4"W Pad Size. Item will be shipped as parts.

I105145-99-0 Bodypoint Monoflex X-Lrge Chest Support Belt Kit 149.00 E096024.5"L x 5"W Pad Size. Item will be shipped as parts.

I106197-99-0 Upper Extremity Support Angle Adjustable 20"W 340.00 E0950Must also select PN I10556.

I106198-99-0 Upper Extremity Support Angle Adjustable 22"W 360.00 E0950Must also select PN I10556.

I10556 Adj Removable - Tray Hardware (1 Each) 222.00 E1028

I105224-99-0 Oxygen Holder, Corpus 3G 235.00 E2208

I105223-99-0 Crutch Holder, Corpus 3G 235.00 E2207

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Stealth Accessories


I10869 Stealth Ultra Headrest 895.00 E0955Includes Stealth Occipital pad (500 series), Sub Occipital pad (600 series) and Flip Down Headrest Mount (TWB480-QFDM). Select Stealth headrests accessories and alternative drive mounts to complete headrest assembly.

I10800 Stealth Swing Away Egg Switch for Ultra Headrest 500.00 E1028Includes Black Egg Switch and Stealth Ultra Swing Away Hardware (SUS9-R). Please indicate if you want switch mounted on left or right side of headrest: Mount Switch on Left: _____ Mount Switch on Right: _____

I10893 Stealth Swing Away Tash Micro Lite for Ultra 575.00 E1028Includes Tash Micro Lite Switch and Stealth Ultra Swing Away Hardware (SUS9-R). Please indicate if you want switch mounted on left or right side of headrest: Mount Switch on Left: _____ Mount Switch on Right: _____

I10801 Stealth Swing Away Facial Supprt Hdw for Ultra 295.00 E1028Must also select support pad (I10810, I10811, I10812). Please indicate if you want it mounted on left or right side of headrest: Mount Hardware on Left: _____ Mount Hardware on Right: _____

I10810 Stealth #900 Support Pad (4.5" x 2") - Ultra 115.00 K0108

I10811 Stealth #910 Support Pad (3" x 2") - Ultra 115.00 K0108

I10812 Stealth #920 Support Pad (6.4" x 2") - Ultra 115.00 K0108

I10718 Stealth Comfort Plus Headrest - 8"W 335.00 E0955Must also select I10721.



I10721 Adj Stealth Headrest Hardware - Each (TWB480) 227.00 E1028Please select headrest post length below: Standard length (10"): _____ Short length (6"): _____

I10736 Stealth Swng Away Egg Sw for Comfort Plus Headrest 500.00 E1028Includes Black Egg Switch and Stealth Comfort Plus Swing Away Hardware (CPS9-R). Please indicate if you want switch mounted on left or right side of headrest: Mount Switch on Left: _____ Mount Switch on Right: _____

I10894 Stealth Swing Away Tash Micro Lite for Cmfrt Plus 575.00 E1028Includes Tash Micro Lite Switch and Stealth Comfort Plus Swing Away Hardware (CPR9-R). Please indicate if you want switch mounted on left or right side of headrest: Mount Switch on Left: _____ Mount Switch on Right: _____

I10809 Stealth Swing Away Facial Supprt Hdw for Cmfrt Plus 295.00 E1028Must also select support pad (I10813, I10814, I10815). Please indicate if you want it mounted on left or right side of headrest: Mount Hardware on Left: _____ Mount Hardware on Right: _____

I10813 Stealth #900 Support Pad (4.5" x 2") - Cmfrt Plus 115.00 K0108

I10814 Stealth #910 Support Pad (3" x 2") - Cmfrt Plus 115.00 K0108

I10815 Stealth #920 Support Pad (6.4" x 2") - Cmfrt Plus 115.00 K0108

I106221-99-0 Stealth 4" x 6" Lateral Supports, HD 350.00 E0956Must also select I10723. Kit contains the thin, Stealth hardware with swing away brackets and two height adjustment rails. The rails are bolted to the backrest to provide mounts for the lateral hardware.

I10723 Adjustable Stealth Lateral Hardware (Pair) 469.00 E1028

Alternative Drive Systems

ALTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:Part Number Description Price HCPCS Code

I10751 Mini-Joystick for Omni / IOM (9-pin connector) 2,590.00 E2312Operating Force = 0.5 oz (13 g) Neutral to Full Deflection = 0.2" (5mm)

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Alternative Drive SystemsALTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:


I103893-99-0 Compact Joystick for Omni / IOM (9-pin connector) 1,264.00 E2373Operating Force = 7.8 oz (220 g) Neutral to Full Deflection = 1.1" (28mm) Joystick includes two 1/8" mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball Knob.

I103894-99-0 Compact Joystick LITE for Omni / IOM (9-pin conn) 1,446.00 E2373Operating Force = 1.8 oz (50 g) Neutral to Full Deflection = 0.7" (17mm) Joystick includes two 1/8" mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball Knob.

CHOOSE MOUNTING HARDWARE:Part Number Description Price HCPCS Code

I104690-99-0 Alt. JS Adjustable Mount Kit - Armrest 222.00 E1028Mount in front of Left Arm: _____ Mount in front of Right Arm: _____

I104695-99-0 Alt. JS Adjustable Mount Kit - Midline 711.00 E1028Mount on Left Arm: _____ Mount on Right Arm: _____

I104143-99-0 Alt. JS Adjustable Mount Kit - Chin Boom 758.00 E1028Swing-Away / Removable Chin Boom mounted on right of backrest shell. Custom charge may be applied if ordering lower backrest heights.

I10752 Alt. JS Adjustable Mount Kit - Haims Harness, Lrg 539.00 E1028For neck width up to 7½".

I10753 Alt. JS Adjustable Mount Kit - Haims Harness, Sml 539.00 E1028For neck width up to 5½".

I10754 Alt. JS Adjustable Mount Kit - Haims Harness, Peds 539.00 E1028For neck width up to 4".

I10068 Alt. JS Adj. Mount Kit - Power SwingAway Chin Boom 4,117.00 K0108Includes power swing away mount off the backrest with adjustable mounting hardware. Custom charge may be applied if ordering lower backrest heights.

I10795 Stealth Swing Away Chin Boom for Ultra Headrest 475.00 E1028Includes Stealth Ultra Swing Away Hardware, 18" boom and bracket for attaching a Mini Joystick or Compact Joystick. Please indicate which bracket to include and if you want boom mounted on left or right side of headrest: Mini Joystick Bracket: _____ Compact Joystick Bracket: _____ Mount Boom on Left: _____ Mount Boom on Right: _____

I10797 Stealth Sw Away Chin Boom for Comfort Plus Headrest 475.00 E1028Includes Stealth Comfort Plus Swing Away Hardware, 18" boom and bracket for attaching a Mini Joystick or Compact Joystick. Please indicate which bracket to include and if you want boom mounted on left or right side of headrest: Mini Joystick Bracket: _____ Compact Joystick Bracket: _____ Mount Boom on Left: _____ Mount Boom on Right: _____

I10807 Stealth Gatlin Eclipse Tray with Mini JS Mount 575.00 E1028Designed to mount on Stealth Gatlin Mid Line Mounts. Includes bracket for mounting a Mini Joystick under tray. Mini Joystick sold separately. Through hole in tray surface provides joystick access. Please indicate side of tray for hole position: Position Hole on Left: _____ Position Hole on Right: _____

ALT JOYSTICK ACCESSORIES:Part Number Description Price HCPCS Code

I104904-99-0 Dual Switches for Compact Joystick - Fixed Mount 226.00 K0108Includes two pushbutton switches mounted on rigid arms. Switches can be used for Mode & On/Off. Switch operation force = 4.5oz (130 g) Mount at front of Joystick: _____ Mount at rear of Joystick: _____ Mount at left of Joystick: _____ Mount at right of Joystick: _____

I104641-99-0 Dual Switches for Compact Joystick -Gooseneck Mount 407.00 K0108Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches are positioned on Left and Right sides of Compact Joystick. Switches can be used for Mode & On/Off. Switch operation force = 4.5oz (130 g)

TOTAL CONTROL HEAD ARRAY SYSTEM:Part Number Description Price HCPCS Code

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TOTAL CONTROL HEAD ARRAY SYSTEM:Part Number Description Price HCPCS Code

I105922-99-0 Permobil Head Array - 3-switch Basic System 4,260.00 E2330Includes Short Adjustable Lateral Arms with Proximity Sensors mounted in Upper Left and Upper Right positions. Short arms can be adjusted from 5.5" to 8" long. ** Complete the Head Array system by choosing pads, hardware and accessories below. ** Choose Omni Control Module (3-sw/5-sw) or R-net Input Module (5-sw only) separately.

CHOOSE OCCIPITAL PAD SIZE (REQUIRED):

I105920-99-0 Small Occipital Pad for Head Array - 4.25"W x 3"H No Charge

I105921-99-0 Large Occipital Pad for Head Array - 6"W x 4"H No Charge .

CHOOSE OCCIPITAL PAD MOUNT (REQUIRED):

I10847 Fixed Mount for Head Array Occipital Pad No Charge

I105936-99-0 Adj. Swivel Mount for Head Array Occipital Pad 380.00 K0108Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms.

CHOOSE BACKREST MOUNTING HARDWARE (REQUIRED):

I105927-99-0 Stealth TWB480 Backrest Mounting Hdwr with Links 235.00 E1028Please select the length of the vertical stem below: Standard length (10"): _____ Short length (6"): _____

I105941-99-0 Stealth TWB480 Backrest Mnt Hdwr with Flipback 390.00 E1028

I105925-99-0 Stealth HMO475 MultiAxis Backrest Mounting Hdwr 200.00 E1028

I10848 Stealth TWB480 Backrest Mnt Hdwr w SubOcptl Mount 425.00 E1028

I10855 Stealth 600 SubOccipital Pad - 8.5" W x 2.75" H 85.00 K0108Must select when PN I10848 is ordered.

SELECT LOWER LEFT ARM PACKAGE (OPTIONAL):

I10859 Add Lateral Arm to Lower Left of Head Array 235.00 E1028Must also select Sensor, Switch or Solid Pad. Choose Lateral Arm Adjustment Range: Short (5.5" - 8"): ______ Long (9" - 13.5"): ______

I10861 Add Proximity Sensor to Lower Left Lateral Arm 310.00 K0108Since Proximity Sensors require power, they CANNOT be used as On/Off switches.

I105917-99-0 Add Egg Switch Assm to Lower Left Lateral Arm 210.00

I105914-99-0 Add Solid Pad to Lower Left Lateral Arm 128.00 K0108 .

SELECT LOWER RIGHT ARM PACKAGE (OPTIONAL):

I10860 Add Lateral Arm to Lower Right of Head Array 235.00 E1028Must also select Sensor, Switch or Solid Pad. Choose Lateral Arm Adjustment Range: Short (5.5" - 8"): ______ Long (9" - 13.5"): ______

I10862 Add Proximity Sensor to Lower Right Lateral Arm 310.00 K0108Since Proximity Sensors require power, they CANNOT be used as On/Off switches.

I105918-99-0 Add Egg Switch Assm to Lower Right Lateral Arm 210.00

I105916-99-0 Add Solid Pad to Lower Right Lateral Arm 128.00 K0108HEAD ARRAY ACCESSORIES:


I105907-99-0 Proximity Sensor + Swivel Assm - Not Mounted 310.00 K0108Since Proximity Sensors require power, they CANNOT be used as On/Off switches.

I105919-99-0 Egg Switch + Swivel Mount Assm - Not Mounted 210.00 K0108

I105912-99-0 Solid Oval Pad + Swivel Assm - Not Mounted 128.00 K0108

I105935-99-0 3.5mm Ext. Cable for Sensor/Switch, 0.3m Long 29.00 K0108

I105931-99-0 3.5mm Ext. Cable for Sensor/Switch, 1m Long 32.00 K0108



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HEAD ARRAY ACCESSORIES:Part Number Description Price HCPCS Code

I105934-99-0 3.5mm Y-splitter Cable for Sensor/Switch 32.00 K0108Allows two Proximity Sensors/Mechanical Switches to connect to the same direction jack.

I10858 PERMOfix Mount Kit for Sensor/Switch on UT Rail 195.00 K0108Enables Sensors/Switches with Swivel Assemblies to be mounted to UniTrack Rails. Kit includes one PERMOfix joint with Flat Plate, hardware to mount to UT rail, one PERMOfix joint with 90° swivel adjustment and two 4" rods.

SIP & PUFF SYSTEMS:Part Number Description Price HCPCS Code

I10573 Sip & Puff System for Omni 1,519.00 E2325,E2326Requires Omni Control Module. Cannot use this part with an Input Module. Includes breath tube kit.

I10574 Sip & Puff System with Fiber Optic Opti-Stop 2,022.00 E2325,E2326Requires Omni Control Module. Cannot use this part with an Input Module. Includes breath tube kit.

I10762 Adjustable Mounting Hrdw - Sip & Puff 222.00 E1028Required when selecting PN I10573 or I10574.

ALTERNATIVE PROPORTIONAL CONTROL SYSTEMS:Part Number Description Price HCPCS Code

I10763 VIC Proportional Finger Control for Omni / IOM 2,568.00 E2328The VIC CCD translates small finger movements into proportional driving commands.

I10764 VIC Adjustable Mount Kit - Armrest 222.00 E1028Mount in front of Left Arm: _____ Mount in front of Right Arm: _____

I10765 VIC Adjustable Mount Kit - Midline 711.00 E1028Mount on Left Arm: _____ Mount on Right Arm: _____

I10317 Proportional Tablet Control for Omni / IOM 4,506.00 E2328The Tablet Control is a unique drive input which enables a user to control a power wheelchair in a very similar manner to a mouse being controlled by a touchpad on a laptop computer. Thedimensions of the Tablet Control Pad are: 12"W x 9.5"D x 1.5" Kit also includes: Buddy Button Switch, and Tablet Control Mounting Bracket.

I10767 Proportional Foot Control 2,724.00Mount on Left: _____ Mount on Right: _____

I10766 Adjustable Mounting Hrdw - Foot Control 222.00 E1028Required when selecting PN I10767.

I10638 RIM Control - SwitchIT for Omni 5,021.00 E2328Requires Omni Control Module. Cannot use this part with an Input Module.

I10770 Adjustable/Removable Hardware - RIM Control 222.00 E1028Required when selecting PN I10638.

Alt Drive Systems Setup

CHOOSE OMNI OR INPUT MODULE (REQUIRED):Part Number Description Price HCPCS Code

ID51154IR Omni Control Module for R-net w/ Infrared 1,541.00Mount in front of Left Arm: _____ Mount in front of Right Arm: _____ Please specify which type of alternative drive input you will be using if not ordering the input device from Permobil. Input Device: ___________________________

I10577 Adjustable Swing-Away Hardware - Omni 222.00 E1028Required when selecting Part Number ID51154IR.

I10581 Input Module (IOM) for R-net Control System 1,042.00 K0108This device allows a proportional or switched drive input to be connected to an R-net Control System without the use of an Omni. It must be ordered in conjunction with an R-net Remote Joystick. It does NOT support any of the following input devices: Sip-n-Puff, 3-Switch / 4-switch Head Array or RIM control.

CHOOSE MOUNTING POSITION OF SEAT CONTROL SWITCHBOX:Part Number Description Price HCPCS Code

I10080 Mount Seat Control Switchbox on Backrest No Charge

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Alt Drive Systems Setup

CHOOSE MOUNTING POSITION OF SEAT CONTROL SWITCHBOX:Part Number Description Price HCPCS Code

I10079 Mount Seat Control Switchbox on Left No Charge

I10078 Mount Seat Control Switchbox on Right No Charge

Alt Drive Accessories


IMICROSWITCH Microlite Switch Qty: _____ 156.00 K0108

IBUDDYBUTTON Buddy Button Qty: _____ 116.00 K0108

I5808 Mini Cup Switch Qty: _____ 113.00 K0108

IZTS-P Proximity Switch Qty: _____ 540.00 K0108

IMINIJOY5SW Mini Joystick 5 Switch OC 621.00 K0108

I10771 Touch Contact with CR2032 Battery Qty: _____ 327.00 K0108

I10772 Dome Switch, Backrest Mnt w Gooseneck Qty: _____ 430.00 K0108Mount on Left: _____ Mount on Right: _____ Mounts at top of backrest shell. Custom charge may be applied if ordering with short backrest heights Kit Includes: One PERMOfix joint with Flat Plate, two PERMOfix joints with 45° swivel adjustment, one 6" rod, one 8" rod and one 9" gooseneck switch with 50" cable and mounting clamp.

I10846 Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty:____ 645.00 K0108Mount on Left: _____ Mount on Right: _____ w 90° Swing-Away Function. Mounts at top of back. Custom charge applies if ordered with short back. Kit Includes: One PERMOfix joint with Flat Plate, one PERMOfix joint with 45° swivel adjustment, two 6" rods, one 90° Swing-Away joint, one 9" gooseneck switch w 50" cable and mounting clamp.

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Additional Order Instructions:

Notes & Comments:

Chair Order Policy:You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms at 1-800-736-0925. The order cannot be processed without the following: -A client name or code, the client’s measurements, the client’s weight -The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil, Inc. is not responsible for configuration or size discrepancies resulting from customer errors on the order form. -Order confirmations will be provided by Permobil 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.

Order Acknowledgement:

I, _________________________, am an agent of the medical equipment provider named on this order form and I have the authority to contract for the purchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete and accurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returns policy and may carry additional charges.

Signed:

Printed Name:

Title:

Date:NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if ordered with the wheelchair. Any parts ordered for service or future alterations will carry different pricing and warranty. MID PROFILE® Cushion is a registered trademark of the The ROHO Group. The HCPCS codes provided are not intended to be billing or legal advice, rather our interpretation of the code definitions. Use of the codes does not ensure coverage or payment for the item. For coverage information, verify the policy of the appropriate payer.

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