PinDot Series Silhouette Order Form Mobility Base Invacare

PinDot Series Silhouette Order Form Rev. 3-1-11 Custom Seating For ease of ordering contact Pindot Customer Service Toll Free at 800-451-3553 Fax 800-834-4153 Attn ContourU 899 Cleveland St. Elyria OH 44036 For Skribbl r Digitizing Systems E-mail Order Form and Digitized File to ElyriaCustomSeating invacare. Com Company Name Contact Name Date E-mail Address Phone Number Fax Number Purchase Order Ship To Address City/State/Zip Account Client Reference Sensor Serial Numbers Back Location Pointer Value Seat Data Form Seat Sensor Back Sensor Strap Back Sensor Back Back Data Form Mobility Base Information / Cushion Dimensions Brand Model Frame Width Inside Rail Width in Frame Depth Inside Back Cane Width Seat Tube Diameter Back Tube Diameter Back Cushion Width degrees inches Seat Cushion Width Seat to Back Angle Seat to Back Gap Is This Order Going With Chair NEW Invacare Chair When ordering cushions With Chair / On Chair fax this order form and the order for the Invacare Chair to Pindot Customer Service at 1-800-834-4153 If Invacare quote is to be converted to order please provide Invacare quote If Freedom wheelchair order will be shipped to Invacare for install please give order HR01S Small Headrest includes Adapter Plate 322. 00 TR40L Tray Receptacle - Left 128. 00 HR02S Large Headrest includes Adapter Plate TR40R HR03S 2-Step Headrest includes Adapter Plate SB05 HR04S Curved Headrest includes Adapter Plate SLK00 ContourU Pelvic Strap Straight Lateral Right or Left 110. 00 HR15 Headrest Adapter Plate 38. 00 SLK05 1/2 Offset Lateral Right or Left AR20 Desk Length Armrest Pair SLK10 AR24 Full Length Armrest Pair SLK15 LB07 Small Footrest Pair SL10S Lateral Insert Replacement Set 250. 00 LB08 Large Footrest Pair PDSLM Mulit-Bar Swingaway Lateral - Medium Pair LT06 Legrest Tops Pair PDSLL HR15 Required when using Contour U pan Comments and Special Instructions Laterals Fit the Silhouette KwikFit Shell Only 40. 00 Seat Cushion Specifications inches variable from 8 to 24 735. 00 Seat cushion 21 or greater additional cost applies - see SO80 on price list Cushion Length 65. 00 Measured from the back of the digitizer to the place on the client s thigh where you want the cushion to end plus and additional 1 Foam Type Soft Firm Extra Firm TFEP TFNP CM06T Mounting To Fit Existing Pan Wx New CU Pan Width x Wood Mount with T-nuts D Depth 195. 00 If selecting Wood Mount specify Cover Type Cover Type IDB/SM IDB/LR Other Draw String Cover Zippered Cover 2-Piece Velcro Cover Infinity Drop Base 14 - 16 wide 291. 00 2 -piece cover not available if undercut selected Removable Covers PLRTK Polartek LYCRA Lycra DARLEX Darlexx DT-2 Standard Dartex Reversed Dartex L-05 Black Rubber Backed Lycra L-06 Grey Rubber Backed Lycra L-13 Light Blue Rubber Backed Lycra L-14 Red Rubber Backed Lycra L-15 Teal Rubber Backed Lycra L-18 Purple Rubber Backed Lycra L-19 Burgundy Rubber Baacked Lycra L-20 Blue Rubber Backed Lycra L-23 L-24 Spacer Mesh Additional Removable Covers SO25 Additional Cover Fabric SO40 Inner Cover Recovery When opting a 2 - tone fabric selection must be indicated as A for contact surface B for Unless otherwise specified Seat Cushion will have Flat Bottom and Hook and Loop Velcro Mount and 4 Curved Rear Mounting Hardware HWWMK78 Wood Mounting Kit - 7/8 inch HWPMK01 Pan Mounting Kit - 1 inch OCMK01 J L Brackets - 1 inch rail cut only FDI-538 Econo-Eze Seat Back Hardware 637.