Silhouette Custom Basic Form 07-030 Revised 5-1-12 Send Order to: Pindot, 899 Cleveland St. Elyria, OH 44036 or V2.3 fax to: 800-834-4153 or Email to: Invacare Wheelchair Order Form Being Sent With This Order: If Yes: Seat Cushion Order Form Cushion Firmness: $835.00 .SM2 * Go to Page 2 for internal use: Gender: Patient Width at Hips: inches Cushion Width: inches Cushion Length: inches * Measure length from the seat back to the place on the client's thigh where the cushion is to end, plus an additional 1" Growth Option: inches * Enter in 1/2" increments, up to 23" cushion depth Additional Deepening: inches * Enter in .01" increments, up to 1.5" max. Shift Contour: inches * Enter in .06" increments, up to 4" max. Additional Minimum Thickness: inches * Default minimum cushion thickness is 1.45" Leg Troughs: inches * Amount to deepen or reduce template leg trough, in 1/4" increments Raise Right Lateral Thigh Support - Width: inches Height: inches From front, extended back: inches Raise Left Lateral Thigh Support - Width: inches Height: inches From front, extended back: inches Increase Medial Thigh Support - Width: inches Height: inches Depth: inches Radius: Taper: Roll: Wedge: inches: Comments or Special Instructions Seat Cushion Modifications Leg Length Discrepancy (SO90) Shorten by: inches $65.00 * Longer Leg will be Cushion Length Indicated Above Location for recess or Sofspot : Front edge of recess to be inches from front of cushion Left edge of recess to be inches from left edge of cushion Size of Recess: Width: inches Length: inches Depth: Type of Recess: $95.00 $150.00 $210.00 $250.00 * Note: If recess is for an air bladder, indicate location of valve (i.e. right-rear or left-front, etc.) in Comments box Rail Cut Options: $65.00 $65.00 Purchase Order #: Seat Design variable from 8" to 23". Additional cost for width or length larger than 20". $65.00 For ease of ordering, contact Pindot Customer Service Toll Free at: 800-451-3553 Company Name: Contact Name: { Ship to Address: Account #: City/State/Zip: [email protected]Phone Number: Fax Number: Cell Phone #: E-mail Address: Date: Client Reference: SN# Yes No With Chair On Chair Soft Firm Extra Firm Male Female Deepen Reduce Right or Left 0 inches 1 inches 2 inches 3 inches 4 inches (Std) 0 inches (Std) 1 inches 2 inches 0 inches 1 inches (Std) 2 inches Front to Back Back to Front Left to Right Right to Left 1 inch 2 inches Recess Only (CM30) Sofspot - Std Foam (CM09) Sofspot - Visco Foam (CM09V) Gel Insert (CM30G) Left Leg Right Leg Standard 1" Wide x 2" Deep for Infinity Drop Base Other: for ContourU Pan User Design File Included with Order - File Name: Apply Design Specifications Listed Below None None None
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Silhouette Custom Basic For ease of ordering, contact Pindot Custom Basic Order...Seat Mounting W x D (TFEP) $240.00 W x D$195.00 $240.00 $195.00 $291.00 $135.00 If Wood Mount Selected,
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Silhouette Custom BasicForm 07-030 Revised 5-1-12
Send Order to: Pindot, 899 Cleveland St. Elyria, OH 44036 or V2.3
fax to: 800-834-4153 or Email to:
Invacare Wheelchair Order Form Being Sent With This Order: If Yes:
Seat Cushion Order Form Cushion Firmness: $835.00
.SM2 * Go to Page 2
for internal use:Gender: Patient Width at Hips: inches
Cushion Width: inchesCushion Length: inches
* Measure length from the seat back to the place on the client's thigh where the cushion is to end, plus an additional 1"
Growth Option: inches * Enter in 1/2" increments, up to 23" cushion depthAdditional Deepening: inches * Enter in .01" increments, up to 1.5" max.Shift Contour: inches * Enter in .06" increments, up to 4" max.Additional Minimum Thickness: inches * Default minimum cushion thickness is 1.45"
Leg Troughs: inches * Amount to deepen or reduce template leg trough, in 1/4" incrementsRaise Right Lateral Thigh Support - Width: inches Height: inches From front, extended back: inchesRaise Left Lateral Thigh Support - Width: inches Height: inches From front, extended back: inchesIncrease Medial Thigh Support - Width: inches Height: inches Depth: inches
* Unless specified otherwise, back cushion will have flat bottom, Hook & Loop Velcro Mount and 4" Curved Top
KwikFit Includes: Shell, Angle Adjustable Interfacing Hardware, Attachment Points for Pindot Headrest, and a Custom Sewn Cover. KwikFit Mounting for Backs will Fit Between the Wheelchair Canes. Cushion and Shell will be Made 2 1/2" Smaller than Wheelchair Width Indicated. Standard KwikFit Mounted Back will have a 2" curved Top.
1 inch 2 inchesRecess Only (CM30) Sofspot - Std Foam (CM09)
Sofspot - Visco Foam (CM09V)Gel Insert (CM30G)
Standard 1" Wide x 2" Deep (SO75)
for KwikFit (SO78)Other:
for ContourU Pan (SO74)
Fit Existing ContourU Pan: Fit New ContourU Pan:
Wood Mount with T-Nuts (CM06T) Wood Mount without T-Nuts (CM06)
Tarsys - Curved Back - 2nd Generation Formula - Contoura
Small Headrest with Adapter Plate (HR01S)Large Headrest with Adapter Plate (HR02S)2-Step Headrest with Adapter Plate (HR03S)Curved Headrest with Adapter Plate (HR04S)Extended Back Mounting Brackets (SMB03)Lateral Insert Replacement Set (SL10S)
Straight Lateral - Left (SLK00)**1/2" Offset Lateral - Left (SLK05)**
Straight Lateral - Right (SRK00)**1/2" Offset Lateral - Right (SRK05)**
$110.00 $110.00$110.00 $110.00$110.00 $110.00
** Laterals Fit the Silhouette KwikFit Shell OnlyNote: All Silhouette accessories are available with the Custom Basic. If an accessory is not listed above, write it in the comments below
Comments or Special Instructions
Invacare Corporation, One Invacare Way, Elyria, OH USA 44036-2125
PinDot, Silhouette and ContourU are registered trademarks of Invacare.
Specifications are subject to change without notification.
Straight Lateral - Left (SLK00)**1/2" Offset Lateral - Left (SLK05)**1" Offset Lateral - Left (SLK10)**1 1/2" Offset Lateral - Left (SLK15)**
Straight Lateral - Right (SRK00)**1/2" Offset Lateral - Right (SRK05)**1" Offset Lateral - Right (SRK10)**1 1/2" Offset Lateral - Right (SRK15)**