AADL Legrests and Armrests Order Form · AADL Legrests and Armrests Order Form This form is...

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AADL Legrests and Armrests Order Form

This form is interactive when viewed with Adobe Acrobat Reader. Complete the form by placing checks in the desired boxes and provide information in the interactive fields. Buttons shown at the bottom of the form may be utilized to print or submit the order form through a desktop email application. To email via a web-based application, please ‘Save As’ and at-tach the PDF to your email. This order form contains a large variety of options to fulfill various patient needs. Descriptions and section notes, such as optional or required, are included to help you complete your order. Other part numbers can be found on the quote ac-knowledgment after this order form is submitted. Please contact Quantum® Sales at 888-570-1113 if assistance is needed. Send the completed order form by fax (866-514-1303) or email ([email protected]). Incomplete forms may delay the quote or order. Customer service will contact you if the order is incomplete or if there are compatibility issues. If special order requests are needed, be sure that the Patient Information section is completed All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete power chair. Please contact technical service for accurate parts ordering.

Please include serial number to ensure compatibility.

Serial number: ___________________________________

Pride Mobility Products Co. FOR AADL USE ONLY 5096 South Service Rd, Beamsville, ON, L0R 1B3Phone: 888-570-1113 | Fax: 866-514-1303 | Email: [email protected]

INTRODUCTION

Account Number: ___________ Date: ________________

Provider Name: __________________________________

Contact: ________________________________________

Phone: ___________________ Fax: _________________

Email: __________________________________________

PO Number: _____________________________________

Marked for: _____________________________________

Ship to Address: _________________________________

City:_________________ Prov:______Postal:_________

Alberta Health - Pharmaceutical and Supplementary Benefits Alberta Aids to Daily Living Parts Prices - Pride Mobility Legrests and Armrests

© 2019 Government of Alberta March 22, 2019

https://get.adobe.com/reader/

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QUANTUM POWER CHAIR ARMRESTS

TRU-Balance 3 Flip-Back, 8”-12”H .................. $145 ea. TRU-Balance 3 RIGHT Flip-Back, 12”-16”H ........ $145 ea.

TRU-Balance® 3 Flip-Back Armrests

Set RIGHT height at:______Set LEFT height at:______

TRU-Balance 3 Armrest Downpost (Pair) .......................................................................................................$95 ea.

Heavy Duty, Removable Armrests

8”-12”H, Single Post, Height Adjustable, ............. $130 ea.Removable, Heavy Duty

10”-14”H, Single Post, Height Adjustable, ............ $130 ea.Removable, Heavy Duty

Set LEFT height at:______ Set RIGHT height at:______

2-Post, Flip Back, Height Adjustable, and Removable Armrests (9”-13” Height) .......................................................$145*

Two-Post ArmrestsSelect the armrest and set the left and right heights. These armrests may interfere with offset backs/ back canes.

Set RIGHT height at:______Set LEFT height at:______

No Armpad Selection and/or See Positioning Components Page or Order Form .................................................. No Charge

Straight, Armpad ......................................... $16 ea. Waterfall, Armpad ........................................ $16 ea.

Falcon Gel ArmpadsSold only in pairs. Select an armpad set below. Armpads are 3” wide. The mounting plate allows the armpad to be offset from the armrest tube.

Foam ArmpadsSelect a left and right standard type armpad (mix or match) OR choose the gel armpads that follow.

Falcon Gel Left and Right Armpad:Full Length .................................................... $150 eaDesk Length .................................................. $100 eaFor use with TB3 standard armrests.

Falcon Gel Left and Right Armpad with Mounting Plate:Full Length. ................................................... $150 eaDesk Length .................................................. $100 eaFor use with 2-Post, Heavy Duty Removable, or Pediatric Armrests.

ARMPADS

14” Full Length 10” Desk Length

ARMREST SIZEREQUIRED. Select a Left (L) and Right (R) armrest size. This also affects the armpad selection below.

Pediatric, Removable Armrests

Pediatric, Height Adjustable, ........................... $145 ea.Removable

Set LEFT height at:______ Set RIGHT height at:______



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QUANTUM POWER CHAIR legrests

5”x6” Footplates 5”x8” Footplates 5”x11” Footplates

Center Mount Footplates

8”-12” ExtensionN/A with Power Articulation.

10”-16” Extension 13”-19” Extension

Center Mount Lower Extension

Center Mount Foot PlatformsIf power articulating foot platform is selected, be sure power legrest control has been selected in previous section.

Power ArticulatingFoot Platform

Set Length at:______

Power Articulating Foot Platform ..........................$3,145Not covered by AADL

Manually Adjustable Center Mount .......................... $265Foot Platform

Small Calf Pad (pair) 6”Wx6”H ................................ $210

Large Calf Pad (pair) 8” taper to 6”Wx8”H ................ $210

Small Calf Panel 18”Wx8”H ................................... $210

Large Calf Panel 24”Wx8”H ................................... $265

Center Mount Calf Support

Width Extension, 8”D and 11”D Footplates .................$55

2” Bell-Shaped Length Extension ..............................$55

4” Outside Edge ...................................................$55

6” Outside Edge ....................................................$55

Reversed Dartex Calf Pad or Panel Cover (pair) .......... $150

Wheel Bumpers (pair) ............................................$30

Footplate Connector ..............................................$55

Modular Footplate Extension Components

Additional Accessories

70° HD Drop-in with 12"-14.5" ....................... $550 Length Lower Extension

Pair part: FRMASMB4762. Left: RIG137706. Right:

RIG137707

70° HD Drop-in with 14.5-18" ........................ $550

Heavy Duty, Drop-in Legrest UpperLeft and Right Legrests will match Left and Right Legrests will not match One Legrest (Left or Right as Marked)

Configuration Verification

Heavy Duty, 70°, Drop-In, Swing-Away LegrestsSelect a configuration, a legrest with extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.

Accessories

6”Wx8”D1 ..........................................$87.50 ea.Pair part: FRMASMB4738. Left: RIG137793. Right: RIG137795.

6”Wx11”D1 .........................................$87.50 ea.Pair part: FRMASMB4741. Left: RIG137796. Right: RIG137797.May cause interference on seat widths less than 18".

8”Wx11”D2 .........................................$87.50 ea.Pair part: FRMASMB4744. Left: RIG137708. Right: RIG137709.May cause interference on seat widths less than 20".

Wheel Bumper(s) ...........................................................................................................................$15 ea.Pair part: WHLASMB1578. Left part: WHL169510. Right part: WHL169511

Angle Adjustable Footplate(s) with Heel Loops



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70° Articulating, Swing-Away Legrests (pair) ............................................................................................ $2,865

11”-13” Length 114.5”-18” Length

Lower Extension

Power Articulating, Swing Away Legrests

Left and Right Legrests will Match Left and Right Legrests will not match One Legrest (Left or Right as Marked)


70° Power Articulating, Swing Away Legrests


Calf Pad (pair) 6”Wx6”H ................................ No Charge Gel Padded Knee Abductor Buttons (pair) ................. $125INDPART2242

Accessories

4”Wx6”D 5”Wx6”D 5”Wx8”D 6”Wx8”D1 6”Wx11”D1 8”Wx11”D2

Angle Adjustable Footplate¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.

60°-90° Swing-Away Legrest ....................................................................................................................$285

60°-90° Swing-Away Legrests

Swing-Away Legrest Upper

Left and Right Legrests will match Left and Right Legrests will not match One Legrest (Left or Right as Marked)


11”-13” LengthN/A with Multi-axis

11”-16.5” LengthOnly with Multi-Axis

13”-16.5” LengthN/A with Multi-Axis

15.5”-19.5” Length

Lower Extension

Set Length at:______Extruded Footplate(s)

Angle Adjustable or Multi Axis Selection

7.25”Wx6”D Extruded Footplate ....................Standard 8.5”Wx6”D Extruded Footplate .....................StandardMay cause interference on seat widths less than 18.”

Angle Adjustable with Heel Loops ................$87.50 ea.(Select footplate size)

Multi-Axis (Select Footplate Size) ................... $260 ea.

4”Wx6”D 5”Wx6”D 5”Wx8”D 6”Wx8”D 6”Wx11”D1 8”Wx11”D2

Angle Adjustable or Multi-Axis Footplate Size¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.

Heel Loops (pair) ..................................................$35Part: FRMASMB7873 Standard on angle adjustable and multi-axis footplates.


Gel Neoprene Footrest Sleeve (pair) ........................ $130Part: INDPART2243

60°-90° Swing-Away Legrest Accessories



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AccessoriesHeel Loops (pair) ..................................................$35Part: FRMASMB7873 Standard on angle adjustable footplates.


Falcon LPW Gel Padded Adductor Buttons (pair) ......... $125Part: INDPART2242

Elevating Legrest Assembly ............................... $550Select lower extension and footplates

HD Elevating Legrest Assembly ........................... $550Select lower extension and footplates

Elevating LegrestLeft and Right Legrests will match Left and Right Legrests will not match One Legrest (Left or Right as Marked)


11”-14” LengthFor reinforced only

12”-14.5” LengthFor angle adjustable only

14”-17” LengthFor reinforced only

14.5”-18” LengthFor angle adjustable only

Lower Extension

Reinforced Cast Footplate(s)7.25”Wx6”D Reinforced Footplate ..................Standard

8.5”Wx6”D Reinforced Footplate ...................StandardMay cause interference on seat widths less than 18.”

Angle Adjustable with Heel Loops ................$87.50 ea.(Select footplate size below)

4”Wx6”D 5”Wx6”D 5”Wx8”D 6”Wx8”D1 6”Wx11”D1 8”Wx11”D2

Angle Adjustable Size¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.


Elevating Legrests

Angle Adjustable Footplate(s)



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Swing-Away (Retractable), Offset Bracket

LITESTREAM MANUAL CHAIR ARMRESTS

Armrests:oTubular Swing-Away 12’’ $290 oSingle Post Height Adjustable Arm (9”-14”H) $315 Armpads

oFull Length, Straight

oDesk Length, Straight

oFull Length, Waterfall

oDesk Length, Waterfall

oHeight Adjustable Dual Post, Flip-Back, Removable1,2 (10.5’’-15.5’’H) $290 Armpads

oFull Length, Straight

oDesk Length, Straight

oFull Length, Waterfall

oDesk Length, Waterfall

LITESTREAM MANUAL CHAIR legrests

Upper:

o60o Swingaways $235

o70o Swingaways $235

o90o Swingaways2,Page1 $235

oElevating Legrests w/ Standard Calf PadsPage2 $415

oElevating Legrests w/ Depth Adjustable Calf Pads $415 Lower:

oShort

oMedium

oLongPage3

Footplates:

oFlip-up Alum Footplate w/Heel LoopPage4 Std

Footplate Size:

o6.5"x 6"Page5o8”x 6"

oComfort Adjustable Composite $135

o4.25’’ o5’’ o6’’

oHeel Loops $40

oAluminum Angle Adjustable $235

o5.5’’ o6.5’’ o7.5’’

oHeel Loops Std

oOmit Heel Loop

oWheel Bumpers $30 Not covered by AADL



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