1 of 4All prices are quoted in US dollars. Prices are subject to change without notice.jw=02-27-20

USA ORDER FORMEFFECTIVE MARCH 1, 2020

PURCHASE ORDER #

COMPANY

DATE

CONTACT NAME

EMAIL

SHIP TO

NAME PHONE

ADDRESS

CITY PROV POSTAL CODE

Model #Carbon Fibre

Model # Aluminum

Fits Width

Height$

CarbonQTY

$Aluminum

QTY

NOACB1307 13”-15” 7” 660

NOACB1309 13”-15” 9” 660

NOACB1313 13”-15” 13” 660

NOACB1316 13”-15” 16” 660

NOACB1407 14”-16” 7” 660

NOCFACB1409 NOACB1409 14”-16” 9” 870 660

NOCFACB1413 NOACB1413 14”-16” 13” 900 660

NOCFACB1416 NOACB1416 14”-16” 16” 930 660

NOACB1507 15”-17” 7” 660

NOCFACB1509 NOACB1509 15”-17” 9” 870 660

NOCFACB1513 NOACB1513 15”-17” 13” 900 660

NOCFACB1516 NOACB1516 15”-17” 16” 930 660

NOACB1607 16”-18” 7” 660

NOCFACB1609 NOACB1609 16”-18” 9” 870 660

NOCFACB1613 NOACB1613 16”-18” 13” 900 660

NOCFACB1616 NOACB1616 16”-18” 16” 930 660

NOACB1619 16”-18” 19” 660

NOACB1707 17”-19” 7” 660

NOCFACB1709 NOACB1709 17”-19” 9” 870 660

NOCFACB1713 NOACB1713 17”-19” 13” 900 660

NOCFACB1716 NOACB1716 17”-19” 16” 930 660

NOACB1719 17”-19” 19” 660

NOACB1807 18”-20” 7” 660

NOCFACB1809 NOACB1809 18”-20” 9” 870 660

NOCFACB1813 NOACB1813 18”-20” 13” 900 660

NOCFACB1816 NOACB1816 18”-20” 16” 930 660

NOACB1819 18”-20” 19” 660

NOACB1916 19”-21” 16” 660

NOACB1919 19”-21” 19” 660

NOACB2007 20”-22” 7” 660

NOCFACB2009 NOACB2009 20”-22” 9” 870 660

NOCFACB2013 NOACB2013 20”-22” 13” 900 660

NOCFACB2016 NOACB2016 20”-22” 16” 930 660

NOACB2019 20”-22” 19” 660

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Model # Carbon Fibre

Model #Aluminum

Fits Width

Height$

CarbonQTY

$Aluminum

QTY

NOPCB1307 13”-15” 7” 660

NOPCB1309 13”-15” 9” 660

NOPCB1313 13”-15” 13” 660

NOPCB1316 13”-15” 16” 660

NOPCB1407 14”-16” 7” 660

NOCFPCB1409 NOPCB1409 14”-16” 9” 965 660

NOCFPCB1413 NOPCB1413 14”-16” 13” 985 660

NOCFPCB1416 NOPCB1416 14”-16” 16” 1025 660

NOPCB1507 15”-17” 7” 660

NOCFPCB1509 NOPCB1509 15”-17” 9” 965 660

NOCFPCB1513 NOPCB1513 15”-17” 13” 985 660

NOCFPCB1516 NOPCB1516 15”-17” 16” 1025 660

NOPCB1607 16”-18” 7” 660

NOCFPCB1609 NOPCB1609 16”-18” 9” 965 660

NOCFPCB1613 NOPCB1613 16”-18” 13” 985 660

NOCFPCB1616 NOPCB1616 16”-18” 16” 1025 660

NOPCB1619 16”-18” 19” 660

NOPCB1707 17”-19” 7” 660

NOCFPCB1709 NOPCB1709 17”-19” 9” 965 660

NOCFPCB1713 NOPCB1713 17”-19” 13” 985 660

NOCFPCB1716 NOPCB1716 17”-19” 16” 1025 660

NOPCB1719 17”-19” 19” 660

NOPCB1807 18”-20” 7” 660

NOCFPCB1809 NOPCB1809 18”-20” 9” 965 660

NOCFPCB1813 NOPCB1813 18”-20” 13” 985 660

NOCFPCB1816 NOPCB1816 18”-20” 16” 1025 660

NOPCB1819 18”-20” 19” 660

NOPCB1916 19”-21” 16” 660

NOPCB1919 19”-21” 19” 660

NOPCB2007 20”-22” 7” 660

NOCFPCB2009 NOPCB2009 20”-22” 9” 965 660

NOCFPCB2013 NOPCB2013 20”-22” 13” 985 660

NOCFPCB2016 NOPCB2016 20”-22” 16” 1025 660

NOPCB2019 20”-22” 19” 660

Optima™ DEEP THORACIC BACK SUPPORT

CARBON FIBRE SHELL = WEIGHT SAVINGS UP TO 2.4 LBS WITH FIXED MICRO-MOUNT HARDWARE OPTION

CARBON FIBRE SHELL = WEIGHT SAVINGS UP TO 2.4 LBS WITH FIXED MICRO-MOUNT HARDWARE OPTION

HCPCS CODE: E2620-E2621 HCPCS CODE: E2620-E2621

2 of 4All prices are quoted in US dollars. Prices are subject to change without notice.jw=02-27-20

Model #Carbon Fibre

Model # Aluminum

Fits Width

Height$

CarbonQTY

$Aluminum

QTY

N/A NOACB2116 21”- 23” 16” N/A 660N/A NOACB2119 21”- 23” 19” N/A 660N/A NOACB2213 22”- 24” 13” N/A 710N/A NOACB2216 22”- 24” 16” N/A 710N/A NOACB2219 22”- 24” 19” N/A 710 N/A NOACB2316 23”- 25” 16” N/A 710N/A NOACB2319 23”- 25” 19” N/A 710N/A NOACB2416 24”-26” 16” N/A 710N/A NOACB2419 24”-26” 19” N/A 710N/A NOACB2516 25”-27” 16” N/A 710N/A NOACB2519 25”-27” 19” N/A 710N/A NOACB2616 26”-28” 16” N/A 710N/A NOACB2619 26”-28” 19” N/A 710N/A NOACB2716 27”-29” 16” N/A 710N/A NOACB2719 27”-29” 19” N/A 710N/A NOACB2816 28”-30” 16” N/A 710N/A NOACB2819 28”-30” 19” N/A 710N/A NOACB2916 29” - 30” 16” N/A 710N/A NOACB2919 29” - 30” 19” N/A 710

Model #Carbon Fibre

Model # Aluminum

Fits Width

Height$

Carbon QTY $

Aluminum QTY

N/A NOPCB2116 21”- 23” 16” N/A 660N/A NOPCB2119 21”- 23” 19” N/A 660N/A NOPCB2213 22”- 24” 13” N/A 710N/A NOPCB2216 22”- 24” 16” N/A 710N/A NOACB2219 22”- 24” 19” N/A 710N/A NOACB2316 23”- 25” 16” N/A 710N/A NOACB2319 23”- 25” 19” N/A 710N/A NOACB2416 24”-26” 16” N/A 710N/A NOACB2419 24”-26” 19” N/A 710N/A NOACB2516 25”-27” 16” N/A 710N/A NOACB2519 25”-27” 19” N/A 710N/A NOACB2616 26”-28” 16” N/A 710N/A NOACB2619 26”-28” 19” N/A 710N/A NOACB2716 27”-29” 16” N/A 710N/A NOACB2719 27”-29” 19” N/A 710N/A NOACB2816 28”-30” 16” N/A 710N/A NOACB2819 28”-30” 19” N/A 710N/A NOACB2916 29” - 30” 16” N/A 710N/A NOACB2919 29” - 30” 19” N/A 710

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Xtend™ Fits Width Height $ QTY

NHAACB1616/20 16”-18” 16”-20” 660

NHAACB1816/20 18”-20” 16”-20” 660

NHAACB2016/20 20”-22” 16”-20” 660

NHAACB2216/20 22”-24” 16”-20” 710

NHAACB2416/20 24”-26” 16”-20” 710

Xtend™

Xtend™ HEIGHT ADJUSTABLE THORACIC BACK SUPPORT

Optima™ THORACIC BACK SUPPORT HCPCS CODE: E2620-E2621

Xtend™ DEEP HEIGHT ADJUSTABLE THORACIC BACK SUPPORT

Optima™ DEEP THORACIC BACK SUPPORT HCPCS CODE: E2620-E2621

Xtend™ Fits Width Height $ QTY

NHAPCB1616/20 16”-18” 16”-20” 660

NHAPCB1816/20 18”-20” 16”-20” 660

NHAPCB2016/20 20”-22” 16”-20” 660

NHAPCB2216/20 22”-24” 16”-20” 710

NHAPCB2416/20 24”-26” 16”-20” 710

Xtend™ DEEP

Xtend™ LOW Fits Width Height $ QTY

NHAACB (L) 1213/17 12”-14” 13”-17” 660

NHAACB (L) 1413/17 14”-16” 13”-17” 660

NHAACB (L) 1613/17 16”-18” 13”-17” 660

NHAACB (L) 1813/17 18”-20” 13”-17” 660

NHAACB (L) 2013/17 20”-22” 13”-17” 660

NHAACB (L) 2213/17 22”-24” 13”-17” 710

Xtend™ KIDS Fits Width Height $ QTY

NHAKCB10/8-10.5 10” 8”-10.5” 625

NHAACB (L) 1413/17 12” 9”-11.5” 625

NHAACB (L) 1613/17 14” 10”-12.5” 625

Xtend™ LOW DEEP Fits Width Height $ QTY

NHAPCB (L) 1213/17 12”-14” 13”-17” 660

NHAPCB (L) 1413/17 14”-16” 13”-17” 660

NHAPCB (L) 1613/17 16”-18” 13”-17” 660

NHAPCB (L) 1813/17 18”-20” 13”-17” 660

NHAPCB (L) 2013/17 20”-22” 13”-17” 660

NHAPCB (L) 2213/17 22”-24” 13”-17” 710

Xtend™ LOW

Xtend™ KIDS

Xtend™ LOW HEIGHT ADJUSTABLE THORACIC BACK SUPPORT

Xtend™ KIDS HEIGHT ADJUSTABLE THORACIC BACK SUPPORT

Xtend™ LOW DEEP HEIGHT ADJUSTABLE THORACIC BACK SUPPORT

Xtend™ LOWDEEP

notes

HCPCS CODE: E2620-E2621

HCPCS CODE: E2620-E2621

HCPCS CODE: E2620-E2621

HCPCS CODE: E2620-E2621

HCPCS CODE: E2620-E2621

3 of 4All prices are quoted in US dollars. Prices are subject to change without notice.jw=02-27-20

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Classic™ PELVIC BACK SUPPORT

Classic™ FitsWidth Height $ QTY

NACB1616 16”-18” 16” 660NACB1618 16”-18” 18” 660NACB1620 16”-18” 20” 660NACB1816 18”-20” 16” 660NACB1818 18”-20” 18” 660NACB1820 18”-20” 20” 660NACB2016 20”-22” 16” 660NACB2018 20”-22” 18” 660NACB2020 20”-22” 20” 660NACB2216 22”-24” 16” 710NACB2218 22”-24” 18” 710NACB2220 22”-24” 20” 710

Classic™ DEEP PELVIC BACK SUPPORT

Classic™ DEEP Fits Width Height $ QTY

NPCB1616 16”-18” 16” 660NPCB1618 16”-18” 18” 660NPCB1620 16”-18” 20” 660NPCB1816 18”-20” 16” 660NPCB1818 18”-20” 18” 660NPCB1820 18”-20” 20” 660NPCB2016 20”-22” 16” 660NPCB2018 20”-22” 18” 660NPCB2020 20”-22” 20” 660NPCB2216 22”-24” 16” 710NPCB2218 22”-24” 18” 710NPCB2220 22”-24” 20” 710

Classic™ DEEPClassic™

üFit™ CUSTOMIZABLE PELVIC BACK SUPPORT

üFit™ Fits Width Height $ QTY

NOUFACB1416 14”-16” 16” 895

NOUFACB1418 14”-16” 18” 895NOUFACB1420 14”-16” 20” 895NOUFACB1616 16”-18” 16” 895NOUFACB1618 16”-18” 18” 895NOUFACB1620 16”-18” 20” 895NOUFACB1816 18”-20” 16” 895NOUFACB1818 18”-20” 18” 895NOUFACB1820 18”-20” 20” 895NOUFACB2016 20”-22” 16” 895NOUFACB2018 20”-22” 18” 895NOUFACB2020 20”-22” 20” 895NOUFACB2216 22”-24” 16” 995NOUFACB2218 22”-24” 18” 995NOUFACB2220 22”-24” 20” 995

Optional Incontinent/Infection Control Cover

üFit™

üFit™ DEEP CUSTOMIZABLE PELVIC BACK SUPPORT

üFit™ DEEP Fits Width Height $ QTY

NOUFPCB1416 14”-16” 16” 995

NOUFPCB1418 14”-16” 18” 995NOUFPCB1420 14”-16” 20” 995NOUFPCB1616 16”-18” 16” 995NOUFPCB1618 16”-18” 18” 995NOUFPCB1620 16”-18” 20” 995NOUFPCB1816 18”-20” 16” 995NOUFPCB1818 18”-20” 18” 995NOUFPCB1820 18”-20” 20” 995NOUFPCB2016 20”-22” 16” 995NOUFPCB2018 20”-22” 18” 995NOUFPCB2020 20”-22” 20” 995NOUFPCB2216 22”-24” 16” 1195NOUFPCB2218 22”-24” 18” 1195NOUFPCB2220 22”-24” 20” 1195Optional Incontinent/Infection Control Cover

üFit™ DEEP

üFit™ II DEEP CUSTOMIZABLE THORACIC BACK SUPPORT

üFit II™ DEEP Fits Width

Back Height $ QTY

NOUFXPCB1416 14”-16” 16” 1045

NOUFXPCB1418 14”-16” 18” 1045NOUFXPCB1420 14”-16” 20” 1045NOUFXPCB1616 16”-18” 16” 1045NOUFXPCB1618 16”-18” 18” 1045NOUFXPCB1620 16”-18” 20” 1045NOUFXPCB1816 18”-20” 16” 1045NOUFXPCB1818 18”-20” 18” 1045NOUFXPCB1820 18”-20” 20” 1045NOUFXPCB2016 20”-22” 16” 1045NOUFXPCB2018 20”-22” 18” 1045NOUFXPCB2020 20”-22” 20” 1045NOUFXPCB2216 22”-24” 16” 1195NOUFXPCB2218 22”-24” 18” 1195NOUFXPCB2220 22”-24” 20” 1195Optional Incontinent/Infection Control Cover

üFit II™ DEEP

üFit™ II CUSTOMIZABLE THORACIC BACK SUPPORT

üFit II™ Fits Width

Back Height $ QTY

NOUFXACB1416 14”-16” 16” 945

NOUFXACB1418 14”-16” 18” 945NOUFXACB1420 14”-16” 20” 945NOUFXACB1616 16”-18” 16” 945NOUFXACB1618 16”-18” 18” 945NOUFXACB1620 16”-18” 20” 945NOUFXACB1816 18”-20” 16” 945NOUFXACB1818 18”-20” 18” 945NOUFXACB1820 18”-20” 20” 945NOUFXACB2016 20”-22” 16” 945NOUFXACB2018 20”-22” 18” 945NOUFXACB2020 20”-22” 20” 945NOUFXACB2216 22”-24” 16” 995NOUFXACB2218 22”-24” 18” 995NOUFXACB2220 22”-24” 20” 995Optional Incontinent/Infection Control Cover

üFit II™

HCPCS CODE: E2620-E2621 HCPCS CODE: E2620-E2621

HCPCS CODE: E2620-E2621 HCPCS CODE: E2620-E2621

HCPCS CODE: E2620-E2621HCPCS CODE: E2620-E2621

4 of 4All prices are quoted in US dollars. Prices are subject to change without notice.jw=02-27-20

Armadillo™ VICAIR

Fits Width

Back Height $ QTY

NVMAPSB14 14”-16” 16”NVMAPSB16 16”-18” 16”

NVMAPSB18 18”-20” 18”

NVMAPSB20 20”-22” 18”

Armadillo™ Fits Width

Back Height $ QTY

NMAPSB14 14”-16” 16” 835NMAPSB16 16”-18” 16” 835

NMAPSB18 18”-20” 18” 835

NMAPSB18-TALL 18”-20” 20” 835

NMAPSB20 20”-22” 18” 835NMAPSB20-TALL 20”-22” 20” 835NMAPSB22 22”-24” 18” 945

NMAPSB22-TALL 22”-24” 20” 945

NMAPSB24 24”-26” 18” 945

NMAPSB24-TALL 24”-26” 20” 945

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EArmadillo™ BACK SUPPORT with VICAIR® TECHNOLOGY CUSHION

Model No. $ QTY

NIB-1937 - 2” Lateral Contour Add-On (Pair) 90

Armadillo™ ADDITIONAL LATERAL CONTOUR ADD-ON

Armadillo™ BACK SUPPORT

Armadillo

VC

VC™ BACK SUPPORT - VICAIR TECHNOLOGY CUSHION

VC Fits Width

Back Height $ QTY

NVCB1616 16”-18 16”NVCB1620 16”-18” 20”

NVCB1816 18”-20” 16”

NVCB1820 18”-20” 20”NVCB2016 20”-22” 16”NVCB2020 20”-22” 20”

MultiFit™ HEAD SUPPORTMODEL NO. MULTI-ADJUSTABLE PADS $ QTY

NIB-0785 9” x 5” CONTOURED 195

NIB-0784 10” x 5” LARGE RECTANGULAR 195

NIB-0818 14” x 5” EXTRA-LARGE RECTANGULAR 195

MODEL NO. FEATURES $ QTY

NIB-0747 MULTI-AXIS HARDWARE 145

NIB-0823 HEAD SUPPORT RECEIVER BRACKET 55

NIB-1306 FLIP BACK MULTI-AXIS HARDWARE 250

NIB-1210 FLIP BACK KIT 105

NIB-1200 UNIVERSAL HEAD SUPPORT ADAPTER 65

Contoured(NIB-0785)

Large(NIB-0784)

Extra large(NIB-0818)

Multi-Axis Hardware(NIB-0747)

Head Support Receiver Bracket (NIB-0823)

BACK SUPPORT HARDWARE OPTIONS

• ALL BACKS COME STANDARD WITH QUICK RELEASE MOUNTING HARDWARE• THE FIXED MOUNTING HARDWARE OPTIONS BELOW ARE NO-CHARGE SUBSTITUTIONS FOR THE STANDARD HARDWARE.

Model No. Description Optima™ Optima™

Carbon Xtend™ Xtend™

LOWXtend™

Kids Classic™ üFit™ Armadillo QTY

NIB-1207 2 Point fixed hardware

Optional 1 Optional N/A N/A N/A Optional

1Optional

1 N/A

NIB-1642

Micro Mount 2 Point

fixed hardware

Optional 2 & 3

Optional 2 & 3 N/A N/A N/A N/A N/A N/A

NIB-1307 4 Point fixed hardware

Optional 3

Optional 3

Optional 3 & 4

Optional 3 & 4 N/A Optional

3Optional

3 N/A

NOTE: 1 – Use only on back supports with 16” (40.6cm) back height or lower. 2 – Use only on back supports with 13” (33cm) back height or lower. 3 – Not width adjustable - fits one back/chair width. 4 – Limits height adjustment to 3”

4-point fixed hardware

2-point fixed hardware

2-point micro mount

notes

HCPCS CODE: E2620-E2621

HCPCS CODE: E0955

NOT AVAILABLE IN USA

NOT AVAILABLE IN USA

5 of 4All prices are quoted in CDN dollars. Prices are subject to change without notice

NüFit™ Fits Width Fits Depth $ QTY

NXCANF1616 15”, 16” 16” 395

NXCANF1618 15”, 16” 18” 395

NXCANF1620 15”, 16” 20” 395

NXCANF1816 17”, 18” 16” 395

NXCANF1818 17”, 18” 18” 395

*NXCANF1820 17”, 18” 20” 395

*NXCANF2016 19”, 20” 16” 395

*NXCANF2018 19”, 20” 18” 395

*NXCANF2020 19”, 20” 19” 395

*NXCANF2216 21”, 22” 21” 425

*NXCANF2218 21”, 22” 21” 425

*NXCANF2220 21”, 22” 21” 425

Optional Incontinent/Infection Control Cover

BioFit™ Fits Width Fits Depth $ QTY

NXCABF1010 10” 10” 425NXCABF1012 10” 12” 425NXCABF1014 10” 14” 425NXCABF1210 11”, 12” 10” 425NXCABF1212 11”, 12” 12” 425NXCABF1214 11”, 12” 14” 425NXCABF1412 13”, 14” 12” 425NXCABF1414 13”, 14” 14” 425NXCABF1416 13”, 14” 16” 425NXCABF1616 15”, 16” 16” 425NXCABF1618 15”, 16” 18” 425NXCABF1620 15”, 16” 20” 425NXCABF1816 17”, 18” 16” 425NXCABF1818 17”, 18” 18” 425NXCABF1820 17”, 18” 20” 425NXCABF1822 17”, 18” 22” 425NXCABF1822 17”, 18” 22” 425NXCABF2016 19”, 20” 16” 425NXCABF2018 19”, 20” 18” 425NXCABF2020 19”, 20” 20” 425NXCABF2022 19”, 20” 20” 425NXCABF2022 19”, 20” 22” 425NXCABF2216 21”, 22” 16” 455NXCABF2218 21”, 22” 18” 455NXCABF2220 21”, 22” 20” 455NXCABF2222 21”, 22” 22” 455NXCABF2222 21”, 22” 22” 455NXCABF2416 23”, 24” 16” 455NXCABF2418 23”, 24” 18” 455NXCABF2420 23”, 24” 20” 455NXCABF2422 23”, 24” 22” 455NXCABF2616 23”, 24” 16” 455NXCABF2618 25”, 26” 18” 455NXCABF2620 25”, 26” 20” 455NXCABF2622 25”, 26” 20” 455

Optional Incontinent/Infection Control Cover

BioFit™

CUSHIONS

753011 Second Line EHS, Orangeville, ON L9W 5W4T: (866) 875-2877 / (519) 942-8441 I F: (866) 875-2878 / (519) 942-2186 I E: orders@dynamichcs.com www.DynamicHCS.com

HCPCS CODE: E0955

NüFit™

HCPCS CODE: E0955