SIZE SELECTION 1 ACTA-RELIEF™ ORDER FORM PRICING IN CANADIAN DOLLARS Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: Shown with Compass ® 4 Quick Release 2 Point Hardware. Cover appearance may vary with hardware selection. *Length (L) refers to the actual size dimension of the support from bottom to top edge. ACTA-RELIEF-ORDER-CA REV0518 ACTA-RELIEF™ ORDER FORM Patient Reference: PAGE 1 of 7 Required 20” 20” 20” LENGTH* FRAME WIDTH 16” 18” 20” 14” BASE MSRP $1,096.25 LENGTH* FRAME WIDTH 14W22L 16W22L 18W22L 20W22L 14W20L 16W20L 18W20L 20W20L 14W18L 16W18L 18W18L 20W18L 14W16L 16W16L 18W16L 20W16L 14W14L 16W14L 18W14L 20W14L 14W12L 16W12L 18W12L 20W12L 14W10L 16W10L 18W10L 20W10L 14W22L 16W22L 18W22L 20W22L 14W20L 16W20L 18W20L 20W20L 14W18L 16W18L 18W18L 20W18L 14W16L 16W16L 18W16L 20W16L 14W14L 16W14L 18W14L 20W14L 14W12L 16W12L 18W12L 20W12L 14W22L 16W22L 18W22L 20W22L 14W20L 16W20L 18W20L 20W20L 14W18L 16W18L 18W18L 20W18L 14W16L 16W16L 18W16L 20W16L 14W14L 16W14L 18W14L 20W14L 14W12L 16W12L 18W12L 20W12L 16” 16” 16” 18” 18” 18” 16” 16” 16” 18” 18” 18” 20” 20” 20” 14” 14” 14” 14” 14” 14” 10” 10” 10” 12” 12” 12” 22” 22” 22” Sizes available with 2 POINT Mounting Hardware LENGTH* FRAME WIDTH Sizes available with 4 POINT Mounting Hardware LENGTH* FRAME WIDTH Sizes available with POWER Mounting Hardware Please fill in one of the above with dimensions from the size charts to the right. Example Part: AR-BS14W16L Hardware will be selected in Section 2. Sizes available are subject to hardware being used. IF DESIRED SIZE IS NOT LISTED, PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.265.9830 AR-BS 16” 18” 20” 14” 12” 10” 22” Acta-Relief Patent Pending 14W10L 16W10L 18W10L 20W10L 14W12L 16W12L 18W12L 20W12L Please note these sizes are not available with lateral trunk supports or a head support. Please note these sizes are not available with 4 POINT when using lateral trunk supports. For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then email or print and fax to Customer Service at [email protected] or 1.877.636.8944
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ACTA-RELIEF ORDER FORM - Permobil · acta-relief™ order form patient reference: page 1 of 7 required 20” 20” 20” length* frame width 14” 16” 18” 20” base msrp $1,096.25
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SIZE SELECTION1
ACTA-RELIEF™
ORDER FORMPRICING IN CANADIAN DOLLARS Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
Shown with Compass® 4 Quick Release 2 Point Hardware. Cover appearance may vary with hardware selection.
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
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ACTA-RELIEF™ ORDER FORM Patient Reference: PAGE 1 of 7
Required
20”
20”
20”
LEN
GTH
*
FRAME WIDTH
16” 18” 20”14”
BASE MSRP $1,096.25
LEN
GTH
*
FRAME WIDTH
14W22L 16W22L 18W22L 20W22L
14W20L 16W20L 18W20L 20W20L
14W18L 16W18L 18W18L 20W18L
14W16L 16W16L 18W16L 20W16L
14W14L 16W14L 18W14L 20W14L
14W12L 16W12L 18W12L 20W12L
14W10L 16W10L 18W10L 20W10L
14W22L 16W22L 18W22L 20W22L
14W20L 16W20L 18W20L 20W20L
14W18L 16W18L 18W18L 20W18L
14W16L 16W16L 18W16L 20W16L
14W14L 16W14L 18W14L 20W14L
14W12L 16W12L 18W12L 20W12L
14W22L 16W22L 18W22L 20W22L
14W20L 16W20L 18W20L 20W20L
14W18L 16W18L 18W18L 20W18L
14W16L 16W16L 18W16L 20W16L
14W14L 16W14L 18W14L 20W14L
14W12L 16W12L 18W12L 20W12L
16”
16”
16”
18”
18”
18”
16”
16”
16”
18”
18”
18”
20”
20”
20”
14”
14”
14”
14”
14”
14”
10”
10”
10”
12”
12”
12”
22”
22”
22”
Sizes available with 2 POINT Mounting Hardware
LEN
GTH
*
FRAME WIDTH
Sizes available with 4 POINT Mounting Hardware
LEN
GTH
*
FRAME WIDTH
Sizes available with POWER Mounting Hardware
Please fill in one of the above with dimensions from the size charts to the right.Example Part: AR-BS14W16L
Hardware will be selected in Section 2.
Sizes available are subject to hardware being used.
IF DESIRED SIZE IS NOT LISTED, PLEASE CONTACT
CUSTOMER SERVICE FOR ASSISTANCE. | 800.265.9830
AR-BS
16”
18”
20”
14”
12”
10”
22”
Acta-Relief Patent Pending
14W10L 16W10L 18W10L 20W10L
14W12L 16W12L 18W12L 20W12L
Please note these sizes are not available with lateral trunk supports or a head support.
Please note these sizes are not available with 4 POINT when using lateral trunk supports.
For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then email or print and fax to Customer Service at [email protected] or 1.877.636.8944
COVER & HARDWARE SELECTION2 Required
2.1
2.2
COVER SELECTION
HARDWARE STYLE
MSRP $0.00
Price included in back support purchase Price included in back support purchase MSRP add $78.13
Latex-free fabric. Fabric selection is for the support surface only. Other fabrics used in cover construction remain the same.
STRETCH-AIR™ Cover (STRETCH-AIR)
QUICK RELEASE 2 POINT (Q-COMPASS)
FIXED 2 POINT(NQ-COMPASS)
QUANTUM w/ TRU BALANCE 3(PMB-QUANTUM)
QUICK RELEASE 4 POINT(Q-COMPASS4)
FIXED 4 POINT(NQ-COMPASS4)
PERMOBIL w/ CORPUS 3G(PMB-PERMOBIL)
QUICKIE w/ 3.7 POWER(PMB-QUICKIE)
AVID REHAB w/ POWER T & R(PMB-AVID)
ROVI w/ MOTION CONCEPTS*(PMB-ROVI)
TOP VIEW
STRETCH-AIR™ has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant.
FIXED fully adjustable hardware requires tools for back support removal
4 POINT hardware is required on all 24”W back supports using Compass® 4 hardware.
POWER MOUNT hardware has 8” of height adjustment in ½” increments without using tools.
COMPASS® 4 QUICK RELEASE COMPASS® 4 FIXED COMPASS® POWER MOUNT
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ACTA-RELIEF™ ORDER FORM Patient Reference: PAGE 2 of 7
*Using Power Mount Hardware on ROVI requires mounting to the RECESSED PLANAR INTERFACE
PLATE available when ordering the Motion Concepts Seating System. Drilling is required for mounting.
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ACTA-RELIEF™ ORDER FORM Patient Reference: PAGE 3 of 7
BODILINK® LATERAL TRUNK SUPPORT & HARDWARE3
Contact Customer Support for custom sizes. 1.800.564.9248.
Continue on next page for cover selection (section 4.3) if basic style pads are selected.
• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.1.• Follow each column down to sections 3.2 and 3.3 (next page) and select a style and cover for each pad selected in section 3.1. Premium pads in section 3.4 on next page.
3.1
3.2
BASIC PAD SIZE & SHAPE
BASIC PAD STYLE
MSRP $145.83/ea.
MSRP $0.00/ea.
*Length (L) refers to the actual size dimension of the support from top to bottom edge. Depth (D) refers to the actual size dimension from anterior to posterior edge.
SHAPE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
SUP
PO
RTI
VE
3”L x 4”D BL-LTSP1S-3L4D-LH BL-LTSP1S-3L4D-LH BL-LTSP1S-3L4D-RH BL-LTSP1S-3L4D-RH
3”L x 5”D BL-LTSP1S-3L5D-LH BL-LTSP1S-3L5D-LH BL-LTSP1S-3L5D-RH BL-LTSP1S-3L5D-RH
4”L x 5”D BL-LTSP1S-4L5D-LH BL-LTSP1S-4L5D-LH BL-LTSP1S-4L5D-RH BL-LTSP1S-4L5D-RH
4”L x 6”D BL-LTSP1S-4L6D-LH BL-LTSP1S-4L6D-LH BL-LTSP1S-4L6D-RH BL-LTSP1S-4L6D-RH
5”L x 7”D BL-LTSP1S-5L7D-LH BL-LTSP1S-5L7D-LH BL-LTSP1S-5L7D-RH BL-LTSP1S-5L7D-RH
6”L x 6”D BL-LTSP1S-6L6D-LH BL-LTSP1S-6L6D-LH BL-LTSP1S-6L6D-RH BL-LTSP1S-6L6D-RH
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3”L x 4”D BL-LTSP1A-3L4D-LH BL-LTSP1A-3L4D-LH BL-LTSP1A-3L4D-RH BL-LTSP1A-3L4D-RH
3”L x 5”D BL-LTSP1A-3L5D-LH BL-LTSP1A-3L5D-LH BL-LTSP1A-3L5D-RH BL-LTSP1A-3L5D-RH
4”L x 5”D BL-LTSP1A-4L5D-LH BL-LTSP1A-4L5D-LH BL-LTSP1A-4L5D-RH BL-LTSP1A-4L5D-RH
4”L x 6”D BL-LTSP1A-4L6D-LH BL-LTSP1A-4L6D-LH BL-LTSP1A-4L6D-RH BL-LTSP1A-4L6D-RH
5”L x 7”D BL-LTSP1A-5L7D-LH BL-LTSP1A-5L7D-LH BL-LTSP1A-5L7D-RH BL-LTSP1A-5L7D-RH
6”L x 6”D BL-LTSP1A-6L6D-LH BL-LTSP1A-6L6D-LH BL-LTSP1A-6L6D-RH BL-LTSP1A-6L6D-RH
• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.4.• Follow each column down to sections 3.5 and 3.6 and select a style and cover for each pad selected in section 3.4.
3.4 PREMIUM PAD SIZE & SHAPEMSRP $197.92/ea.
*Length (L) refers to the dimension of the support from top to bottom edge. Depth (D) refers to the dimension of the support from anterior to posterior edge.
SHAPE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
SUP
PO
RTI
VE
3”L x 4”D BL-LTSP2S-3L4D-LH BL-LTSP2S-3L4D-LH BL-LTSP2S-3L4D-RH BL-LTSP2S-3L4D-RH
3”L x 5.5”D BL-LTSP2S-3L5D-LH BL-LTSP2S-3L5D-LH BL-LTSP2S-3L5D-RH BL-LTSP2S-3L5D-RH
4”L x 5”D BL-LTSP2S-4L5D-LH BL-LTSP2S-4L5D-LH BL-LTSP2S-4L5D-RH BL-LTSP2S-4L5D-RH
4”L x 6.5”D BL-LTSP2S-4L6D-LH BL-LTSP2S-4L6D-LH BL-LTSP2S-4L6D-RH BL-LTSP2S-4L6D-RH
5”L x 6.5”D BL-LTSP2S-5L6D-LH BL-LTSP2S-5L6D-LH BL-LTSP2S-5L6D-RH BL-LTSP2S-5L6D-RH
6”L x 6.5”D BL-LTSP2S-6L6D-LH BL-LTSP2S-6L6D-LH BL-LTSP2S-6L6D-RH BL-LTSP2S-6L6D-RH
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3”L x 4”D BL-LTSP2A-3L4D-LH BL-LTSP2A-3L4D-LH BL-LTSP2A-3L4D-RH BL-LTSP2A-3L4D-RH
3”L x 5.5”D BL-LTSP2A-3L5D-LH BL-LTSP2A-3L5D-LH BL-LTSP2A-3L5D-RH BL-LTSP2A-3L5D-RH
4”L x 5”D BL-LTSP2A-4L5D-LH BL-LTSP2A-4L5D-LH BL-LTSP2A-4L5D-RH BL-LTSP2A-4L5D-RH
4”L x 6.5”D BL-LTSP2A-4L6D-LH BL-LTSP2A-4L6D-LH BL-LTSP2A-4L6D-RH BL-LTSP2A-4L6D-RH
5”L x 6.5”D BL-LTSP2A-5L6D-LH BL-LTSP2A-5L6D-LH BL-LTSP2A-5L6D-RH BL-LTSP2A-5L6D-RH
6”L x 6.5”D BL-LTSP2A-6L6D-LH BL-LTSP2A-6L6D-LH BL-LTSP2A-6L6D-RH BL-LTSP2A-6L6D-RH
SUPPORTIVE
ACTIVE
OR
L
L
D
D
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ACTA-RELIEF™ ORDER FORM Patient Reference: PAGE 4 of 7
3.5
3.6
PREMIUM PAD STYLE
PREMIUM PAD COVER
MSRP $0.00/ea.
COVER OPTIONS MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
NO COVER $0.00/ea. LTS-P2-NO-CV LTS-P2-NO-CV LTS-P2-NO-CV LTS-P2-NO-CV
Both Fixed and Swing-Away hardware styles are adjustable.
3.8GT2 MOUNTING HARDWARE
Open Position
Release Button
• You may make one selection per column in section 3.8.
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ACTA-RELIEF™ ORDER FORM Patient Reference: PAGE 6 of 7
14W x 5L Head Support Pad Pictured
BODILINK® HEAD SUPPORT HARDWARE & PADS3
FOR AIR TRANSMISSION & HEAT DISSIPATION.
STRETCH-AIR
FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.
L
3.2 PREMIUM PAD COVER MATERIAL
GlideWear® (GLIDEWEAR) (add $78.13)
Stretch-Air (STRETCH-AIR)
Length (L) refers to the actual size dimension of the support from bottom to top edge.
PREMIUM PAD SIZE MSRP $235.00
4.1
Premium Head Support Pads angles can be
formed by adjusting the plates in the pad.
• You may make one selection per column.• Choose between premium (3.1) -or- basic (3.3).• Choose a cover material in 3.2 -or- 3.4.
W
W
Pad Firmness
L
L
L
L
L
FOR AIR TRANSMISSION & HEAT DISSIPATION.
STRETCH-AIR
3.4 BASIC PAD COVER MATERIAL
Stretch-Air (STRETCH-AIR)
Basic head support pads can be formed
to any shape using the moldable steel insert
inside the pad.
BASIC PAD SIZEMSRP $235.00
3.3
6W x 5L BL-HSP3-6W5L
8W x 5L BL-HSP3-8W5L
10W x 6L BL-HSP3-10W6L
12W x 6L BL-HSP3-12W6L
14W x 6L BL-HSP3-14W6L
18W x 6L BL-HSP3-18W6L
L
L
L
L
L
L
W
W
Length (L) refers to the actual size dimension of the support from bottom to top edge.
3.5 HEAD SUPPORT HARDWARE
SIZE & SHAPE MSRP PART NUMBER
MID 6 $338.54 (BL-HS-PT1RMMID6)
LAT 6 $442.71 (BL-HS-PT1RMLAT6)
MID 8 $338.54 (BL-HS-PT1RMMID8)
LAT 8 $442.71 (BL-HS-PT1RMLAT8)
MAX 8* $494.79 (BL-HS-PT1RMMAX8)
*Provides the greatest amount of articulation and range of motion.
PT HARDWARE, REMOVABLEA.
PT
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RE
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ID 6
PT
HA
RD
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RE
, L
AT
6
PT
HA
RD
WA
RE
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ID 8
PT
HA
RD
WA
RE
, L
AT
8
PT
HA
RD
WA
RE
, M
AX
8
• You may make one selection per column in either A -or- B.• If choosing 3.5 A, choose a stem length option next.• Choose which mounting block option you require in 3.6.
PT MODEL
TOTAL # OF
LINKS
TOTAL LINK
LENGTH
MAX. ANTERIOR
REACH
MAX. POSTERIOR
REACH
MAX. LATERAL REACH
MID 6 2 6” 5.5” 1” N/A
LAT 6 3 6” 5.5” 1” 6”
MID 8 2 8” 7.5” 1” N/A
LAT 8 3 8” 7.5” 1” 8”
MAX 8 4 8” 7.5” 3” 8”
PT HARDWARE RANGE OF MOTION
6W x 3LSoft BL-HSP1-6W3L
Extra Soft BL-HSP2-6W3L
8W x 4LSoft BL-HSP1-8W4L
Extra Soft BL-HSP2-8W4L
10W x 5Lwith adjustable wings
Soft BL-HSP1-10W5L
Extra Soft BL-HSP2-10W5L
12W x 5Lwith adjustable wings
Soft BL-HSP1-12W5L
Extra Soft BL-HSP2-12W5L
14W x 5Lwith adjustable wings
Soft BL-HSP1-14W5L
Extra Soft BL-HSP2-14W5L
18W x 5Lwith adjustable wings
Soft BL-HSP1-18W5L
Extra Soft BL-HSP2-18W5L
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ACTA-RELIEF™ ORDER FORM Patient Reference: PAGE 7 of 7
SIZE & SHAPE MSRP PART NUMBER
LATERAL $317.71 (BL-HS-GT3RMLAT)
MID-LINE $281.25 (BL-HS-GT3RMMID)
GT HARDWARE, REMOVABLEB.
GT
HA
RD
WA
RE
, L
AT
ER
AL
GT
HA
RD
WA
RE
, M
ID-L
INE
GT MODEL
TOTAL # OF
LINKS
TOTAL LINK
LENGTH
MAX. ANTERIOR
REACH
MAX. POSTERIOR
REACH
MAX. LATERAL REACH
LAT 5 10.5” 10” 2” 7.5”
MID 3 8.5” 8” 2” N/A
GT HARDWARE RANGE OF MOTION
MOUNTING BLOCK OR BRACKET WITH BLOCK MSRP PART NUMBER
*ACTA-RELIEF™ 14W BRACKET WITH MOUNTING BLOCK $145.83 (HS-MB-AR14W)
*ACTA-RELIEF™ 16W BRACKET WITH MOUNTING BLOCK $145.83 (HS-MB-AR16W)
*ACTA-RELIEF™ 18W BRACKET WITH MOUNTING BLOCK $145.83 (HS-MB-AR18W)
*ACTA-RELIEF™ 20W BRACKET WITH MOUNTING BLOCK $145.83 (HS-MB-AR20W)
POSTERIOR A MOUNTING BLOCK $0.00 (HS-MB-POSTA)
3.6 HEAD SUPPORT MOUNTING OPTION
MOUNTING BLOCK-POSTERIOR A
For Acta-Relief with Power Mount Only
STEM LENGTH MSRP PART NUMBER
STANDARD 7” STEM $0.00 (HS-STEM-7)
***3” STEM $0.00 (HS-STEM-3)
PT HARDWARE, STEM LENGTH OPTION
ST
AN
DA
RD
P
T S
TE
M, 7
”
PT
ST
EM
, 3
”
***3” Stem is recommended for use with power mounting where there may be special constraints with power chair functions
PT HARDWARE (CONTINUED)
BRACKET WITH MOUNTING BLOCK-
ACTA-RELIEF™18W Shown Above
For Non-Power Mount Only.
*For Acta Relief™, includes mounting bracket and POSTA block. If you already have an Acta-Relief™ head support bracket, order POSTA Block