www.icrehab.com version 5-14 Custom Contoured Seat Order Form - MSRP Page One Phone 800.676.5030 Fax 330.545.6389 Office Use Only: Knob Release Kit (2-Point Mount)................................. #13007-15 One Inch Drop, U-Clamp Hardware Mounting Kit........... #2200-99 Velcro Hook & Loop Attachment (seat pan mount) ...... #13009-PM No Charge Omit Mounting Hardware................................................ ($35.00) Mounting Hardware-Options Foam In Place Kits 1/2 unit size..........................................................................#13011-FIP 1-full unit size.....................................................................#13011-FIP2 Soft Sunmate Soft Sunmate Medium Sunmate Medium Sunmate Qty: Qty: A- B- C- D- E- F- G- H- I- J- 1" Drop Hook Kit............................................................ #2211-99 2" Drop Hook Kit............................................................ #2213-99 3"Drop Hook Kit.............................................................. #2215-99 No Charge No Charge No Charge Flush-Mount U-Clamp Hardware Mounting Kit............... Cushion Separated from wood.............................#13007-22 $128.00 Full-Width Custom Contoured Seat................#13003-SA Seat-Mount Information Standard Oversized Seat Upgrade..................................... #13007-05 $114.00 Actual Seat width 20-23" or > 20" deep Between-The-Rails-Custom Contoured Seat.....#13003-SA Mounting Location Flush Mount 1" Drop 2" Drop 3" Drop No Charge Seat width will be 3'' narrower than chair width Seat Contour-Options Note- Standard foam contour selection will pre-determine ABD/ADD and the Anti-thrust heights inside cushion. Custom dimensions can be made in-lieu or in-junction with the standard foam contour selections. Custom dimension selections will override standard contour selections. Mild Foam Contours (1/2 inch build-ups) Moderate Foam Contours (1 inch build-ups) Aggressive Foam Contours (1-1/2 inch build-ups) Custom Contoured Seat................................#13003-SA...........$965.00 Track Mount Hardware............................... #13010-TM2 T-Nut for Attachment ................................................................ No Charge Omit Track & T-nuts..................................................................... ($6.00) Omit Wood ................................................................................. ($6.00) A- B- Seat Tubing Size 7/8" Tubing Size 1" Tubing Size QUOTE ORDER PO# Other : Company Name: Phone # Client Name: W/C Make: W/C Model: W/C Width: Seat Depth: Non-Rehab Frame Contact Name: Frame Color: HCPC E2609 No Charge #2199-99 Knob Release Kit (4-Point Mount).............................. #13010-19 Standard must be ordered with Back 2-point kit w/seat-to-back-brackets No Charge $154.00 $209.00 No Charge NEW FEATURES! Includes: 4 -Point knob release mounting hardware, premium foam and Upholstery upgrade Standard Bariatric Seat Upgrade..................................... #13007-06 $155.00 Actual Seat width 24" Bariatric Oversized Seat Upgrade ...................... #13007-07 $201.00 Actual Seat width 25-30"
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Custom Contoured Seat Order Form - MSRP ONE Fabric Style For Contact Surface Select ONE Fabric Style For Non-Contact Surface
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Mounting Location Flush Mount 1" Drop 2" Drop 3" Drop
No ChargeSeat width will be 3'' narrower than chair width
Seat Contour-OptionsNote- Standard foam contour selection will pre-determine ABD/ADD and the Anti-thrust heights inside cushion. Custom dimensions can be made in-lieu or in-junction with the standard foam contour selections. Custom dimension selections will override standard contour selections.
Small Pad (A-3") (B-4") (C-3") (D-2.5") ..................................#11059-10.........$259.00
Medium Pad (A-4") (B-5") (C-3") (D-3.5") ................................#11059-11........$259.00
Knee Abductor "Econo-Removable" (E0957 / E1028)
(Pad and hardware included)
Large Pad (A-5") (B-6") (C-3") (D-4.5") ...................................#11059-12....... . $259.00
Custom Size Pad (specify dimensions below)....................................#11059-15.........$304.00.
Abductor Pad / Options / Upgrades
SunMate foam / dartex uph.................... (no charge)
Special foam / upholstery............... #0099................ $30.00
Small Pad (A-3") (B-4") (C-3") (D-2.5")..........................#11060-10........... $362.00Medium Pad (A-4") (B-5") (C-3") (D-3.5".........................#11060-11...........) $362.00
Flip-Down Knee Abductor (E0957 / E1028)
(Pad and hardware included)
Large Pad (A-5") (B-6") (C-3") (D-4.5")............................#11060-12.......... $362.00Custom Size Pad (specify dimensions below) ...........................#11060-15......... $410.00
Large (10"-12" Circumference)......................#110451-L...................$156.00
Ankle Cuffs
Medium (8"-10"Circumference)......................#110451-M..................$156.00Small (6"-8" Circumference)..........................#110451-S...................$156.00
Side Release (Pair) Adjustable mount
Large (10"-12" Circumference)......................#110452-L...................$156.00
Medium (8"-10" Circumference).....................#110452-M..................$156.00Small (6"-8" Circumference)..........................#110452-S...................$156.00