ADJUSTER X ORDER FORM Patient Reference: PAGE 1 of 6 *DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.* $455.00 $455.00 $579.00 $579.00 $503.00 $503.00 SIZE & STYLE 1 ADJUSTER ® X ORDER FORM Adjuster ® X shown with GlideWear ® DEPTH DEPTH WIDTH WIDTH 21” 21” 14” 14” 22” 22” 15” 15” 23” 23” 16” 16” 10” 10” 18” 18” 24” 24” 14” 14” 28” 28” 11” 11” 19” 19” 25” 25” 15” 15” 29” 29” 12” 12” 20” 20” 26” 26” 16” 16” 22” 22” 30” 30” 13” 13” 21” 21” 27” 27” 17” 17” 23” 23” 20” 20” 13” 13” 19” 19” 12” 12” 18” 18” 11” 11” 10” 10” 24” 24” 17” 17” STRETCH-AIR™ COMFORT-TEK™ Please select size in the appropriate fabric chart below. GlideWear ® cover options found on page 2. AJX-F-1824 AJX-F-1924 AJX-F-2024 AJX-F-2124 AJX-F-2224 AJX-F-2324 AJX-F-2424 AJX-F-2524 AJX-F-2624 AJX-F-2724 AJX-F-2824 AJX-F-2924 AJX-F-3024 AJX-F-1823 AJX-F-1923 AJX-F-2023 AJX-F-2123 AJX-F-2223 AJX-F-2323 AJX-F-2423 AJX-F-2523 AJX-F-2623 AJX-F-2723 AJX-F-2823 AJX-F-2923 AJX-F-3023 AJX-F-1622 AJX-F-1722 AJX-F-1822 AJX-F-1922 AJX-F-2022 AJX-F-2122 AJX-F-2222 AJX-F-2322 AJX-F-2422 AJX-F-2522 AJX-F-2622 AJX-F-2722 AJX-F-2822 AJX-F-2922 AJX-F-3022 AJX-F-1521 AJX-F-1621 AJX-F-1721 AJX-F-1821 AJX-F-1921 AJX-F-2021 AJX-F-2121 AJX-F-2221 AJX-F-2321 AJX-F-2421 AJX-F-2521 AJX-F-2621 AJX-F-2721 AJX-F-2821 AJX-F-2921 AJX-F-3021 AJX-F-1420 AJX-F-1520 AJX-F-1620 AJX-F-1720 AJX-F-1820 AJX-F-1920 AJX-F-2020 AJX-F-2120 AJX-F-2220 AJX-F-2320 AJX-F-2420 AJX-F-2520 AJX-F-2620 AJX-F-2720 AJX-F-2820 AJX-F-2920 AJX-F-3020 AJX-F-1419 AJX-F-1519 AJX-F-1619 AJX-F-1719 AJX-F-1819 AJX-F-1919 AJX-F-2019 AJX-F-2119 AJX-F-2219 AJX-F-2319 AJX-F-2419 AJX-F-2519 AJX-F-2619 AJX-F-2719 AJX-F-2819 AJX-F-2919 AJX-F-3019 AJX-F-1218 AJX-F-1318 AJX-F-1418 AJX-F-1518 AJX-F-1618 AJX-F-1718 AJX-F-1818 AJX-F-1918 AJX-F-2018 AJX-F-2118 AJX-F-2218 AJX-F-2318 AJX-F-2418 AJX-F-2518 AJX-F-2618 AJX-F-2718 AJX-F-2818 AJX-F-2918 AJX-F-3018 AJX-F-1117 AJX-F-1217 AJX-F-1317 AJX-F-1417 AJX-F-1517 AJX-F-1617 AJX-F-1717 AJX-F-1817 AJX-F-1917 AJX-F-2017 AJX-F-2117 AJX-F-2217 AJX-F-2317 AJX-F-2417 AJX-F-1016 AJX-F-1116 AJX-F-1216 AJX-F-1316 AJX-F-1416 AJX-F-1516 AJX-F-1616 AJX-F-1716 AJX-F-1816 AJX-F-1916 AJX-F-2016 AJX-F-2116 AJX-F-2216 AJX-F-2316 AJX-F-2416 AJX-F-1015 AJX-F-1115 AJX-F-1215 AJX-F-1315 AJX-F-1415 AJX-F-1515 AJX-F-1615 AJX-F-1715 AJX-F-1815 AJX-F-1915 AJX-F-2015 AJX-F-1014 AJX-F-1114 AJX-F-1214 AJX-F-1314 AJX-F-1414 AJX-F-1514 AJX-F-1614 AJX-F-1714 AJX-F-1814 AJX-F-1914 AJX-F-1013 AJX-F-1113 AJX-F-1213 AJX-F-1313 AJX-F-1413 AJX-F-1513 AJX-F-1613 AJX-F-1713 AJX-F-1012 AJX-F-1112 AJX-F-1212 AJX-F-1312 AJX-F-1412 AJX-F-1512 AJX-F-1612 AJX-F-1712 AJX-F-1011 AJX-F-1111 AJX-F-1211 AJX-F-1311 AJX-F-1411 AJX-F-1511 AJX-F-1010 AJX-F-1110 AJX-F-1210 AJX-F-1310 AJX-F-1410 AJX-F-1510 AJX-S-1824 AJX-S-1924 AJX-S-2024 AJX-S-2124 AJX-S-2224 AJX-S-2324 AJX-S-2424 AJX-S-2524 AJX-S-2624 AJX-S-2724 AJX-S-2824 AJX-S-2924 AJX-S-3024 AJX-S-1823 AJX-S-1923 AJX-S-2023 AJX-S-2123 AJX-S-2223 AJX-S-2323 AJX-S-2423 AJX-S-2523 AJX-S-2623 AJX-S-2723 AJX-S-2823 AJX-S-2923 AJX-S-3023 AJX-S-1622 AJX-S-1722 AJX-S-1822 AJX-S-1922 AJX-S-2022 AJX-S-2122 AJX-S-2222 AJX-S-2322 AJX-S-2422 AJX-S-2522 AJX-S-2622 AJX-S-2722 AJX-S-2822 AJX-S-2922 AJX-S-3022 AJX-S-1521 AJX-S-1621 AJX-S-1721 AJX-S-1821 AJX-S-1921 AJX-S-2021 AJX-S-2121 AJX-S-2221 AJX-S-2321 AJX-S-2421 AJX-S-2521 AJX-S-2621 AJX-S-2721 AJX-S-2821 AJX-S-2921 AJX-S-3021 AJX-S-1420 AJX-S-1520 AJX-S-1620 AJX-S-1720 AJX-S-1820 AJX-S-1920 AJX-S-2020 AJX-S-2120 AJX-S-2220 AJX-S-2320 AJX-S-2420 AJX-S-2520 AJX-S-2620 AJX-S-2720 AJX-S-2820 AJX-S-2920 AJX-S-3020 AJX-S-1419 AJX-S-1519 AJX-S-1619 AJX-S-1719 AJX-S-1819 AJX-S-1919 AJX-S-2019 AJX-S-2119 AJX-S-2219 AJX-S-2319 AJX-S-2419 AJX-S-2519 AJX-S-2619 AJX-S-2719 AJX-S-2819 AJX-S-2919 AJX-S-3019 AJX-S-1218 AJX-S-1318 AJX-S-1418 AJX-S-1518 AJX-S-1618 AJX-S-1718 AJX-S-1818 AJX-S-1918 AJX-S-2018 AJX-S-2118 AJX-S-2218 AJX-S-2318 AJX-S-2418 AJX-S-2518 AJX-S-2618 AJX-S-2718 AJX-S-2818 AJX-S-2918 AJX-S-3018 AJX-S-1117 AJX-S-1217 AJX-S-1317 AJX-S-1417 AJX-S-1517 AJX-S-1617 AJX-S-1717 AJX-S-1817 AJX-S-1917 AJX-S-2017 AJX-S-2117 AJX-S-2217 AJX-S-2317 AJX-S-2417 AJX-S-1016 AJX-S-1116 AJX-S-1216 AJX-S-1316 AJX-S-1416 AJX-S-1516 AJX-S-1616 AJX-S-1716 AJX-S-1816 AJX-S-1916 AJX-S-2016 AJX-S-2116 AJX-S-2216 AJX-S-2316 AJX-S-2416 AJX-S-1015 AJX-S-1115 AJX-S-1215 AJX-S-1315 AJX-S-1415 AJX-S-1515 AJX-S-1615 AJX-S-1715 AJX-S-1815 AJX-S-1915 AJX-S-2015 AJX-S-1014 AJX-S-1114 AJX-S-1214 AJX-S-1314 AJX-S-1414 AJX-S-1514 AJX-S-1614 AJX-S-1714 AJX-S-1814 AJX-S-1914 AJX-S-1013 AJX-S-1113 AJX-S-1213 AJX-S-1313 AJX-S-1413 AJX-S-1513 AJX-S-1613 AJX-S-1713 AJX-S-1012 AJX-S-1112 AJX-S-1212 AJX-S-1312 AJX-S-1412 AJX-S-1512 AJX-S-1612 AJX-S-1712 AJX-S-1011 AJX-S-1111 AJX-S-1211 AJX-S-1311 AJX-S-1411 AJX-S-1511 AJX-S-1010 AJX-S-1110 AJX-S-1210 AJX-S-1310 AJX-S-1410 AJX-S-1510 OR COMFORT-TEK™ FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE. STRETCH-AIR™ FOR PATIENT COMFORT & HEAT DISSIPATION. HCPCS CODING: E2622/E2623 ADJUSTABLE SKIN PROTECTION Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: 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 Support at [email protected] or 1.406.522.8563 *DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
ADJUSTER X ORDER FORM Patient Reference: PAGE 1 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
$455.00
$455.00
$579.00
$579.00
$503.00
$503.00
SIZE & STYLE1
ADJUSTER® X ORDER FORM
Adjuster® X shown with GlideWear®
DEP
THD
EPTH
WIDTH
WIDTH
21”
21”
14”
14”
22”
22”
15”
15”
23”
23”
16”
16”
10”
10”
18”
18”
24”
24”
14”
14”
28”
28”
11”
11”
19”
19”
25”
25”
15”
15”
29”
29”
12”
12”
20”
20”
26”
26”
16”
16”
22”
22”
30”
30”
13”
13”
21”
21”
27”
27”
17”
17”
23”
23”
20”
20”
13”
13”
19”
19”
12”
12”
18”
18”
11”
11”
10”
10”
24”
24”
17”
17”
STRETCH-AIR™
COMFORT-TEK™
Please select size in the appropriate fabric chart below.GlideWear® cover options found on page 2.
AJX-F-1824 AJX-F-1924 AJX-F-2024 AJX-F-2124 AJX-F-2224 AJX-F-2324 AJX-F-2424 AJX-F-2524 AJX-F-2624 AJX-F-2724 AJX-F-2824 AJX-F-2924 AJX-F-3024
AJX-F-1823 AJX-F-1923 AJX-F-2023 AJX-F-2123 AJX-F-2223 AJX-F-2323 AJX-F-2423 AJX-F-2523 AJX-F-2623 AJX-F-2723 AJX-F-2823 AJX-F-2923 AJX-F-3023
AJX-F-1622 AJX-F-1722 AJX-F-1822 AJX-F-1922 AJX-F-2022 AJX-F-2122 AJX-F-2222 AJX-F-2322 AJX-F-2422 AJX-F-2522 AJX-F-2622 AJX-F-2722 AJX-F-2822 AJX-F-2922 AJX-F-3022
AJX-F-1521 AJX-F-1621 AJX-F-1721 AJX-F-1821 AJX-F-1921 AJX-F-2021 AJX-F-2121 AJX-F-2221 AJX-F-2321 AJX-F-2421 AJX-F-2521 AJX-F-2621 AJX-F-2721 AJX-F-2821 AJX-F-2921 AJX-F-3021
AJX-F-1420 AJX-F-1520 AJX-F-1620 AJX-F-1720 AJX-F-1820 AJX-F-1920 AJX-F-2020 AJX-F-2120 AJX-F-2220 AJX-F-2320 AJX-F-2420 AJX-F-2520 AJX-F-2620 AJX-F-2720 AJX-F-2820 AJX-F-2920 AJX-F-3020
AJX-F-1419 AJX-F-1519 AJX-F-1619 AJX-F-1719 AJX-F-1819 AJX-F-1919 AJX-F-2019 AJX-F-2119 AJX-F-2219 AJX-F-2319 AJX-F-2419 AJX-F-2519 AJX-F-2619 AJX-F-2719 AJX-F-2819 AJX-F-2919 AJX-F-3019
AJX-F-1218 AJX-F-1318 AJX-F-1418 AJX-F-1518 AJX-F-1618 AJX-F-1718 AJX-F-1818 AJX-F-1918 AJX-F-2018 AJX-F-2118 AJX-F-2218 AJX-F-2318 AJX-F-2418 AJX-F-2518 AJX-F-2618 AJX-F-2718 AJX-F-2818 AJX-F-2918 AJX-F-3018
AJX-F-1117 AJX-F-1217 AJX-F-1317 AJX-F-1417 AJX-F-1517 AJX-F-1617 AJX-F-1717 AJX-F-1817 AJX-F-1917 AJX-F-2017 AJX-F-2117 AJX-F-2217 AJX-F-2317 AJX-F-2417
AJX-F-1016 AJX-F-1116 AJX-F-1216 AJX-F-1316 AJX-F-1416 AJX-F-1516 AJX-F-1616 AJX-F-1716 AJX-F-1816 AJX-F-1916 AJX-F-2016 AJX-F-2116 AJX-F-2216 AJX-F-2316 AJX-F-2416
AJX-F-1015 AJX-F-1115 AJX-F-1215 AJX-F-1315 AJX-F-1415 AJX-F-1515 AJX-F-1615 AJX-F-1715 AJX-F-1815 AJX-F-1915 AJX-F-2015
AJX-F-1014 AJX-F-1114 AJX-F-1214 AJX-F-1314 AJX-F-1414 AJX-F-1514 AJX-F-1614 AJX-F-1714 AJX-F-1814 AJX-F-1914
AJX-F-1013 AJX-F-1113 AJX-F-1213 AJX-F-1313 AJX-F-1413 AJX-F-1513 AJX-F-1613 AJX-F-1713
AJX-F-1012 AJX-F-1112 AJX-F-1212 AJX-F-1312 AJX-F-1412 AJX-F-1512 AJX-F-1612 AJX-F-1712
AJX-F-1011 AJX-F-1111 AJX-F-1211 AJX-F-1311 AJX-F-1411 AJX-F-1511
AJX-F-1010 AJX-F-1110 AJX-F-1210 AJX-F-1310 AJX-F-1410 AJX-F-1510
AJX-S-1824 AJX-S-1924 AJX-S-2024 AJX-S-2124 AJX-S-2224 AJX-S-2324 AJX-S-2424 AJX-S-2524 AJX-S-2624 AJX-S-2724 AJX-S-2824 AJX-S-2924 AJX-S-3024
AJX-S-1823 AJX-S-1923 AJX-S-2023 AJX-S-2123 AJX-S-2223 AJX-S-2323 AJX-S-2423 AJX-S-2523 AJX-S-2623 AJX-S-2723 AJX-S-2823 AJX-S-2923 AJX-S-3023
AJX-S-1622 AJX-S-1722 AJX-S-1822 AJX-S-1922 AJX-S-2022 AJX-S-2122 AJX-S-2222 AJX-S-2322 AJX-S-2422 AJX-S-2522 AJX-S-2622 AJX-S-2722 AJX-S-2822 AJX-S-2922 AJX-S-3022
AJX-S-1521 AJX-S-1621 AJX-S-1721 AJX-S-1821 AJX-S-1921 AJX-S-2021 AJX-S-2121 AJX-S-2221 AJX-S-2321 AJX-S-2421 AJX-S-2521 AJX-S-2621 AJX-S-2721 AJX-S-2821 AJX-S-2921 AJX-S-3021
AJX-S-1420 AJX-S-1520 AJX-S-1620 AJX-S-1720 AJX-S-1820 AJX-S-1920 AJX-S-2020 AJX-S-2120 AJX-S-2220 AJX-S-2320 AJX-S-2420 AJX-S-2520 AJX-S-2620 AJX-S-2720 AJX-S-2820 AJX-S-2920 AJX-S-3020
AJX-S-1419 AJX-S-1519 AJX-S-1619 AJX-S-1719 AJX-S-1819 AJX-S-1919 AJX-S-2019 AJX-S-2119 AJX-S-2219 AJX-S-2319 AJX-S-2419 AJX-S-2519 AJX-S-2619 AJX-S-2719 AJX-S-2819 AJX-S-2919 AJX-S-3019
AJX-S-1218 AJX-S-1318 AJX-S-1418 AJX-S-1518 AJX-S-1618 AJX-S-1718 AJX-S-1818 AJX-S-1918 AJX-S-2018 AJX-S-2118 AJX-S-2218 AJX-S-2318 AJX-S-2418 AJX-S-2518 AJX-S-2618 AJX-S-2718 AJX-S-2818 AJX-S-2918 AJX-S-3018
AJX-S-1117 AJX-S-1217 AJX-S-1317 AJX-S-1417 AJX-S-1517 AJX-S-1617 AJX-S-1717 AJX-S-1817 AJX-S-1917 AJX-S-2017 AJX-S-2117 AJX-S-2217 AJX-S-2317 AJX-S-2417
AJX-S-1016 AJX-S-1116 AJX-S-1216 AJX-S-1316 AJX-S-1416 AJX-S-1516 AJX-S-1616 AJX-S-1716 AJX-S-1816 AJX-S-1916 AJX-S-2016 AJX-S-2116 AJX-S-2216 AJX-S-2316 AJX-S-2416
AJX-S-1015 AJX-S-1115 AJX-S-1215 AJX-S-1315 AJX-S-1415 AJX-S-1515 AJX-S-1615 AJX-S-1715 AJX-S-1815 AJX-S-1915 AJX-S-2015
AJX-S-1014 AJX-S-1114 AJX-S-1214 AJX-S-1314 AJX-S-1414 AJX-S-1514 AJX-S-1614 AJX-S-1714 AJX-S-1814 AJX-S-1914
AJX-S-1013 AJX-S-1113 AJX-S-1213 AJX-S-1313 AJX-S-1413 AJX-S-1513 AJX-S-1613 AJX-S-1713
AJX-S-1012 AJX-S-1112 AJX-S-1212 AJX-S-1312 AJX-S-1412 AJX-S-1512 AJX-S-1612 AJX-S-1712
AJX-S-1011 AJX-S-1111 AJX-S-1211 AJX-S-1311 AJX-S-1411 AJX-S-1511
AJX-S-1010 AJX-S-1110 AJX-S-1210 AJX-S-1310 AJX-S-1410 AJX-S-1510
ORCOMFORT-TEK™
FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.
STRETCH-AIR™FOR PATIENT COMFORT
& HEAT DISSIPATION.
HCPCS CODING: E2622/E2623 ADJUSTABLE SKIN PROTECTION
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
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 Support at [email protected] or 1.406.522.8563*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
ADJUSTER X ORDER FORM Patient Reference: PAGE 2 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.736.0925
GLIDEWEAR® is designed to promote healing as well as reduce the risk of skin breakdown. A GlideWear® Shear Reduction Panel is incorporated into the cover under the most at-risk areas to allow for micro-movements without the deformation of tissue.
U.S. GLIDEWEAR® Patent No. 8,646,459
ADJUSTER® X wItHPlease select size in the appropriate fabric chart below.
$490.00 $619.00$538.00
DEP
TH
WIDTH
21”
14”
22”
15”
23”
16”
10” 18” 24”14” 28”11” 19” 25”15” 29”12” 20” 26”16” 22” 30”13” 21” 27”17” 23”
20”
13”
19”
12”
18”
11”10”
24”
17”
COMFORT-TEK™ with GLIDEWEAR®
AJX-FQ-1824 AJX-FQ-1924 AJX-FQ-2024 AJX-FQ-2124 AJX-FQ-2224 AJX-FQ-2324 AJX-FQ-2424 AJX-FQ-2524 AJX-FQ-2624 AJX-FQ-2724 AJX-FQ-2824 AJX-FQ-2924 AJX-FQ-3024
AJX-FQ-1823 AJX-FQ-1923 AJX-FQ-2023 AJX-FQ-2123 AJX-FQ-2223 AJX-FQ-2323 AJX-FQ-2423 AJX-FQ-2523 AJX-FQ-2623 AJX-FQ-2723 AJX-FQ-2823 AJX-FQ-2923 AJX-FQ-3023
AJX-FQ-1622 AJX-FQ-1722 AJX-FQ-1822 AJX-FQ-1922 AJX-FQ-2022 AJX-FQ-2122 AJX-FQ-2222 AJX-FQ-2322 AJX-FQ-2422 AJX-FQ-2522 AJX-FQ-2622 AJX-FQ-2722 AJX-FQ-2822 AJX-FQ-2922 AJX-FQ-3022
AJX-FQ-1521 AJX-FQ-1621 AJX-FQ-1721 AJX-FQ-1821 AJX-FQ-1921 AJX-FQ-2021 AJX-FQ-2121 AJX-FQ-2221 AJX-FQ-2321 AJX-FQ-2421 AJX-FQ-2521 AJX-FQ-2621 AJX-FQ-2721 AJX-FQ-2821 AJX-FQ-2921 AJX-FQ-3021
AJX-FQ-1420 AJX-FQ-1520 AJX-FQ-1620 AJX-FQ-1720 AJX-FQ-1820 AJX-FQ-1920 AJX-FQ-2020 AJX-FQ-2120 AJX-FQ-2220 AJX-FQ-2320 AJX-FQ-2420 AJX-FQ-2520 AJX-FQ-2620 AJX-FQ-2720 AJX-FQ-2820 AJX-FQ-2920 AJX-FQ-3020
AJX-FQ-1419 AJX-FQ-1519 AJX-FQ-1619 AJX-FQ-1719 AJX-FQ-1819 AJX-FQ-1919 AJX-FQ-2019 AJX-FQ-2119 AJX-FQ-2219 AJX-FQ-2319 AJX-FQ-2419 AJX-FQ-2519 AJX-FQ-2619 AJX-FQ-2719 AJX-FQ-2819 AJX-FQ-2919 AJX-FQ-3019
AJX-FQ-1218 AJX-FQ-1318 AJX-FQ-1418 AJX-FQ-1518 AJX-FQ-1618 AJX-FQ-1718 AJX-FQ-1818 AJX-FQ-1918 AJX-FQ-2018 AJX-FQ-2118 AJX-FQ-2218 AJX-FQ-2318 AJX-FQ-2418 AJX-FQ-2518 AJX-FQ-2618 AJX-FQ-2718 AJX-FQ-2818 AJX-FQ-2918 AJX-FQ-3018
AJX-FQ-1117 AJX-FQ-1217 AJX-FQ-1317 AJX-FQ-1417 AJX-FQ-1517 AJX-FQ-1617 AJX-FQ-1717 AJX-FQ-1817 AJX-FQ-1917 AJX-FQ-2017 AJX-FQ-2117 AJX-FQ-2217 AJX-FQ-2317 AJX-FQ-2417
AJX-FQ-1016 AJX-FQ-1116 AJX-FQ-1216 AJX-FQ-1316 AJX-FQ-1416 AJX-FQ-1516 AJX-FQ-1616 AJX-FQ-1716 AJX-FQ-1816 AJX-FQ-1916 AJX-FQ-2016 AJX-FQ-2116 AJX-FQ-2216 AJX-FQ-2316 AJX-FQ-2416
AJX-FQ-1015 AJX-FQ-1115 AJX-FQ-1215 AJX-FQ-1315 AJX-FQ-1415 AJX-FQ-1515 AJX-FQ-1615 AJX-FQ-1715 AJX-FQ-1815 AJX-FQ-1915 AJX-FQ-2015
AJX-FQ-1014 AJX-FQ-1114 AJX-FQ-1214 AJX-FQ-1314 AJX-FQ-1414 AJX-FQ-1514 AJX-FQ-1614 AJX-FQ-1714 AJX-FQ-1814 AJX-FQ-1914
AJX-FQ-1013 AJX-FQ-1113 AJX-FQ-1213 AJX-FQ-1313 AJX-FQ-1413 AJX-FQ-1513 AJX-FQ-1613 AJX-FQ-1713
AJX-FQ-1012 AJX-FQ-1112 AJX-FQ-1212 AJX-FQ-1312 AJX-FQ-1412 AJX-FQ-1512 AJX-FQ-1612 AJX-FQ-1712
AJX-FQ-1011 AJX-FQ-1111 AJX-FQ-1211 AJX-FQ-1311 AJX-FQ-1411 AJX-FQ-1511
AJX-FQ-1010 AJX-FQ-1110 AJX-FQ-1210 AJX-FQ-1310 AJX-FQ-1410 AJX-FQ-1510
$490.00 $619.00$538.00
DEP
TH
WIDTH
21”
14”
22”
15”
23”
16”
10” 18” 24”14” 28”11” 19” 25”15” 29”12” 20” 26”16” 22” 30”13” 21” 27”17” 23”
20”
13”
19”
12”
18”
11”10”
24”
17”
STRETCH-AIR™ with GLIDEWEAR®
AJX-SQ-1824 AJX-SQ-1924 AJX-SQ-2024 AJX-SQ-2124 AJX-SQ-2224 AJX-SQ-2324 AJX-SQ-2424 AJX-SQ-2524 AJX-SQ-2624 AJX-SQ-2724 AJX-SQ-2824 AJX-SQ-2924 AJX-SQ-3024
AJX-SQ-1823 AJX-SQ-1923 AJX-SQ-2023 AJX-SQ-2123 AJX-SQ-2223 AJX-SQ-2323 AJX-SQ-2423 AJX-SQ-2523 AJX-SQ-2623 AJX-SQ-2723 AJX-SQ-2823 AJX-SQ-2923 AJX-SQ-3023
AJX-SQ-1622 AJX-SQ-1722 AJX-SQ-1822 AJX-SQ-1922 AJX-SQ-2022 AJX-SQ-2122 AJX-SQ-2222 AJX-SQ-2322 AJX-SQ-2422 AJX-SQ-2522 AJX-SQ-2622 AJX-SQ-2722 AJX-SQ-2822 AJX-SQ-2922 AJX-SQ-3022
AJX-SQ-1521 AJX-SQ-1621 AJX-SQ-1721 AJX-SQ-1821 AJX-SQ-1921 AJX-SQ-2021 AJX-SQ-2121 AJX-SQ-2221 AJX-SQ-2321 AJX-SQ-2421 AJX-SQ-2521 AJX-SQ-2621 AJX-SQ-2721 AJX-SQ-2821 AJX-SQ-2921 AJX-SQ-3021
AJX-SQ-1420 AJX-SQ-1520 AJX-SQ-1620 AJX-SQ-1720 AJX-SQ-1820 AJX-SQ-1920 AJX-SQ-2020 AJX-SQ-2120 AJX-SQ-2220 AJX-SQ-2320 AJX-SQ-2420 AJX-SQ-2520 AJX-SQ-2620 AJX-SQ-2720 AJX-SQ-2820 AJX-SQ-2920 AJX-SQ-3020
AJX-SQ-1419 AJX-SQ-1519 AJX-SQ-1619 AJX-SQ-1719 AJX-SQ-1819 AJX-SQ-1919 AJX-SQ-2019 AJX-SQ-2119 AJX-SQ-2219 AJX-SQ-2319 AJX-SQ-2419 AJX-SQ-2519 AJX-SQ-2619 AJX-SQ-2719 AJX-SQ-2819 AJX-SQ-2919 AJX-SQ-3019
AJX-SQ-1218 AJX-SQ-1318 AJX-SQ-1418 AJX-SQ-1518 AJX-SQ-1618 AJX-SQ-1718 AJX-SQ-1818 AJX-SQ-1918 AJX-SQ-2018 AJX-SQ-2118 AJX-SQ-2218 AJX-SQ-2318 AJX-SQ-2418 AJX-SQ-2518 AJX-SQ-2618 AJX-SQ-2718 AJX-SQ-2818 AJX-SQ-2918 AJX-SQ-3018
AJX-SQ-1117 AJX-SQ-1217 AJX-SQ-1317 AJX-SQ-1417 AJX-SQ-1517 AJX-SQ-1617 AJX-SQ-1717 AJX-SQ-1817 AJX-SQ-1917 AJX-SQ-2017 AJX-SQ-2117 AJX-SQ-2217 AJX-SQ-2317 AJX-SQ-2417
AJX-SQ-1016 AJX-SQ-1116 AJX-SQ-1216 AJX-SQ-1316 AJX-SQ-1416 AJX-SQ-1516 AJX-SQ-1616 AJX-SQ-1716 AJX-SQ-1816 AJX-SQ-1916 AJX-SQ-2016 AJX-SQ-2116 AJX-SQ-2216 AJX-SQ-2316 AJX-SQ-2416
AJX-SQ-1015 AJX-SQ-1115 AJX-SQ-1215 AJX-SQ-1315 AJX-SQ-1415 AJX-SQ-1515 AJX-SQ-1615 AJX-SQ-1715 AJX-SQ-1815 AJX-SQ-1915 AJX-SQ-2015
AJX-SQ-1014 AJX-SQ-1114 AJX-SQ-1214 AJX-SQ-1314 AJX-SQ-1414 AJX-SQ-1514 AJX-SQ-1614 AJX-SQ-1714 AJX-SQ-1814 AJX-SQ-1914
AJX-SQ-1013 AJX-SQ-1113 AJX-SQ-1213 AJX-SQ-1313 AJX-SQ-1413 AJX-SQ-1513 AJX-SQ-1613 AJX-SQ-1713
AJX-SQ-1012 AJX-SQ-1112 AJX-SQ-1212 AJX-SQ-1312 AJX-SQ-1412 AJX-SQ-1512 AJX-SQ-1612 AJX-SQ-1712
AJX-SQ-1011 AJX-SQ-1111 AJX-SQ-1211 AJX-SQ-1311 AJX-SQ-1411 AJX-SQ-1511
AJX-SQ-1010 AJX-SQ-1110 AJX-SQ-1210 AJX-SQ-1310 AJX-SQ-1410 AJX-SQ-1510
ORCOMFORT-TEK™
FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.
STRETCH-AIR™FOR PATIENT COMFORT
& HEAT DISSIPATION.
ADJU
STER
X-O
RDER
REV
0129
19
ADJUSTER X ORDER FORM Patient Reference: PAGE 3 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
Red (RED) Silver Reflective (SILVER)
Purple (PURPLE) Green (GREEN)
Pink (PINK) Remove (REMOVE)
Orange (ORANGE)
2 *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items.ADJUSTER® X ACCESSORIES
Solid Seat Pan & Hardware Kit(RSSP-N-HARD)
2.5REMOVABLE SOLID SEAT PAN & HARDWARE KITHCPCS Code: E2231 MSRP $387.00
Rigid Insert Not Glued(RGD-INSERT-UNGLUED)
2.6 RIGID INSERTHCPCS Code: E0992 MSRP $65.00
The solid seat pan kit includes a slotted aluminum pan and attaching hardware to accommodate 7/8” or 1” tubing. The kit also comes with two different cross bars to accommodate various wheelchair frame types. This will fit both folding and non-folding seat rails. Lateral thigh support hardware can be easily attached.
3/16” Plastic rigidizing board.
2.3
Liner provides extra incontinence protection for the cushion.
One Incontinence Liner (INCON-LINER)
Two Incontinence Liners (INCON-LINER)
2.4
One Extra Stretch Air Outer Cover (X-STRETCH-AIR-CV)
Two Extra Stretch Air Outer Cover (2X-STRETCH-AIR-CV)
One Extra Comfort Tek Outer Cover (X-COMFORT-TEK-CV)
Two Extra Comfort Tek Outer Cover (2X-COMFORT-TEK-CV)
Kwik Strap®
(KWIK-STRAP)
2.2 KWIK STRAP®
MSRP $16.00
Kwik Strap® provides extra security. Kwik Strap® is connected to the bottom of the cushion via hook & loop attachment and wraps around vertical canes to secure the cushion to wheelchair during transfers.
Rear View
2.7 EXTRA VICAIR® AIR CELLSMSRP $43.00 / 50 air cell pack
Pack of 50 Vicair® Air Cells (AIRCELL50)
2.8 VICAIR® PELVIC STABILIZER MSRP $118.00
(fits) 16W x 16D -OR- 16W x 18D (PS-1618)
(fits) 18W x 16D -OR- 18W x 18D (PS-1818)
2.1COLOR - COMES STANDARD W/ REFLECTIVE BLUE PIPINGMSRP $26.00
Accent colors can be applied to the cushion via colored piping. If no colors are selected, our standard reflective blue piping is used.
COLOR LOCATION
INCONTINENCE LINERMSRP One = $60.00 - Two = $120.00
EXTRA COVERMSRP One = $62.00 - Two = $124.00
ADJU
STER
X-O
RDER
REV
0129
19
ADJUSTER X ORDER FORM Patient Reference: PAGE 4 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE & PADS3 Please select sizes in the appropriate fabric &
style charts below. Contact Customer Support for custom sizes that are not listed below 800.736.0925.
STYLE SIZE LEFT EXTRA LEFT RIGHT EXTRA RIGHT
3.5”L x 4”D BL-LPTSP2Z-3L4D-LH BL-LPTSP2Z-3L4D-LH BL-LPTSP2Z-3L4D-RH BL-LPTSP2Z-3L4D-RH
3.5”L x 8”D BL-LPTSP2Z-3L8D-LH BL-LPTSP2Z-3L8D-LH BL-LPTSP2Z-3L8D-RH BL-LPTSP2Z-3L8D-RH
3.5”L x 12”D BL-LPTSP2Z-3L12D-LH BL-LPTSP2Z-3L12D-LH BL-LPTSP2Z-3L12D-RH BL-LPTSP2Z-3L12D-RH
5.5”L x 6”D BL-LPTSP2Z-5L6D-LH BL-LPTSP2Z-5L6D-LH BL-LPTSP2Z-5L6D-RH BL-LPTSP2Z-5L6D-RH
3.1 PREMIUM PAD SIZE & SHAPEHCPCS Code: E0953 MSRP $62.00
*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.
• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.1.• Make a fabric selection in 3.2.
COVER OPTIONS MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT
COMFORT-TEK™ $0.00/ea. LPTS-P2-COMFORT-FM LPTS-P2-COMFORT-FM LPTS-P2-COMFORT-FM LPTS-P2-COMFORT-FM
STRETCH-AIR™ $0.00/ea. LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM
GLIDEWEAR® $13.00/ea. LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM
FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.
STRETCH-AIR™FOR PATIENT COMFORT &
HEAT DISSIPATION.
COMFORT-TEK™FOR FLUID PROTECTION & AN
EASILY CLEANED SURFACE.
3.2 PREMIUM PAD COVER WITH FOAM INSERT
L
D
3.3
TT HARDWARE, SLOT MOUNT
A.
BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE
• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.3 from group A, B, -OR- C.
• TT long extention arms (section 3.4) will only work with TT style hardware.
SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT
FIXE
D
SMALL $141.00 BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-RH BL-LPTS-TT1FXSL1-RH
MEDIUM $141.00 BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-RH BL-LPTS-TT1FXSL2-RH
LARGE $141.00 BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-RH BL-LPTS-TT1FXSL3-RH
REM
OVA
BLE
E102
8
SMALL $248.00 BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-RH BL-LPTS-TT1RMSL1-RH
MEDIUM $248.00 BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-RH BL-LPTS-TT1RMSL2-RH
LARGE $248.00 BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-RH BL-LPTS-TT1RMSL3-RH
HARDWARE SIZEMAX CUSHION
THICKNESS CLEARANCE
RECOMMENDED CUSHION
THICKNESS
SMALL 3.0” 2.0”- 3.0”
MEDIUM 4.5” 3.0”- 4.5”
LARGE 6.5” 4.0”- 6.5”
TT H
ARD
WAR
E SL
OT
MO
UN
T- F
IXED
TT H
ARD
WAR
E SL
OT
MO
UN
T-
REM
OVA
BLE
SMALL MEDIUM LARGE
HARDWARE SIZE VS. CUSHION THICKNESS
2.0”- 3.0”
3.0”- 4.5”
4.0”- 6.5”
OR
ADJU
STER
X-O
RDER
REV
0129
19
ADJUSTER X ORDER FORM Patient Reference: PAGE 5 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
TT H
ARD
WAR
E PO
WER
MO
UN
T- F
IXED
TT H
ARD
WAR
E PO
WER
MO
UN
T-
REM
OVA
BLE
SMALL MEDIUM LARGE
HARDWARE SIZE VS. CUSHION THICKNESS
2.0”- 3.5”
3.0”- 5.5”
4.0”- 7.5”
TT HARDWARE, POWER MOUNT B.HARDWARE SIZE
MAX CUSHION THICKNESS CLEARANCE
RECOMMENDED CUSHION
THICKNESS
SMALL 3.5” 2.0”- 3.5”
MEDIUM 5.5” 3.0”- 5.5”
LARGE 7.5” 4.0”- 7.5”
SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT
FIXE
D
SMALL $185.00 BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-RH BL-LPTS-TT1FXPWL1-RH
MEDIUM $185.00 BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-RH BL-LPTS-TT1FXPWL2-RH
LARGE $185.00 BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-RH BL-LPTS-TT1FXPWL3-RH
REM
OVA
BLE
E102
8
SMALL $285.00 BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-RH BL-LPTS-TT1RMPWL1-RH
MEDIUM $285.00 BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-RH BL-LPTS-TT1RMPWL2-RH
LARGE $285.00 BL-LPTS-TT1RMPWL3-LH BL-LPTS-TT1RMPWL3-LH BL-LPTS-TT1RMPWL3-RH BL-LPTS-TT1RMPWL3-RH
NOTE: If choosing the Power Mount Hardware, choose the appropriate power mount type below.
POWER MOUNT MSRP PART NUMBER
QUANTUM add $0.00 LPTS-TT1-PW1
PERMOBIL add $0.00 LPTS-TT1-PW2
QUICKIE add $0.00 LPTS-TT1-PW3
ROVI add $0.00 LPTS-TT1-PW4
AVID REHAB add $0.00 LPTS-TT1-PW5
TT HARDWARE, POWER MOUNT OPTION
OR
BODILINK® MEDIAL KNEE/THIGH SUPPORT HARDWARE & PADS4
STYLE SIZE PART NUMBER
2.5”W x 3.5”D BL-MKTSP1-3W4D
3.5”W x 5”D BL-MKTSP1-4W5D
4”W x 6”D BL-MKTSP1-4W6D
2.5”W x 3.5”D BL-MKTSP2-3W4D
3.5”W x 5”D BL-MKTSP2-4W5D
5”W x 6”D BL-MKTSP2-5W6D
COMFORT-TEK FOR FLUID PROTECTION & AN EASILY CLEANED
SURFACE.
FOR PATIENT COMFORT& HEAT DISSIPATION.
STRETCH-AIR
FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.
4.2 PAD COVER MATERIAL
GlideWear® (MKTSP-GLIDE) (add $15.00)
Comfort-Tek (MKTSP-COMFORT)
Stretch-Air (MKTSP-STRETCH)
PAD SIZE & SHAPE HCPCS CODING: E0957 MSRP $130.00
4.1
• You may make one selection per column.• Choose between wedge or oval in 4.1.• Choose a cover material in 4.2. • Choose hardware size in 4.3.
D
W
WEDGE
OVAL
W
LEFT EXTRA LEFT RIGHT EXTRA RIGHT
BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4
3.4 TT LONG EXTENSION ARM 4” MSRP $37.00/arm
ADJU
STER
X-O
RDER
REV
0129
19
ADJUSTER X ORDER FORM Patient Reference: PAGE 6 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
SUBMIT BY EMAIL
4.3MEDIAL KNEE/THIGH SUPPORT SWING AWAY HARDWAREHCPCS CODING: E1028 MSRP $180.00
SIZE RECOMMENDED INFERIOR THIGH THICKNESS
Small 1.00”- 3.00”
Medium 2.00”- 5.00”
Large 3.00”- 7.00”
SIZE PART NUMBER
SMALL BL-MKTS-ST1SASL1
MEDIUM BL-MKTS-ST1SASL2
LARGE BL-MKTS-ST1SASL3SMALL MEDIUM LARGE
*Swing Away Hardware only, not available in Fixed Hardware**MKTS Hardware must be mounted to Removable Solid Seat
Pan in section 2.4***If Leg Length Discrepancy is needed on Removable Solid
Seat Pan, Offset Orientation must be selected
Inferior Thigh Thickness
Related Documents
