SIZE SELECTION 1 LENGTH* FRAME WIDTH 16” 18” 20” 16” 18” 20” 22” 14” 24” 22” VISCO BACK ® ORDER FORM HCPCS CODING: E2611/E2612 GENERAL USE BACK Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: $514.00 $590.00 $439.00 $514.00 Shown with Compass ® 4 Quick Release 2 Point Hardware. *Length (L) refers to the actual size dimension of the support from bottom to top edge. BASE MSRP BY SIZE VISCO-BACK-ORDER REV0316 LENGTH* FRAME WIDTH 16W22L 18W22L 20W22L 22W22L 16W20L 18W20L 20W20L 22W20L 16W18L 18W18L 20W18L 22W18L 16W16L 18W16L 20W16L 22W16L 16W14L 18W14L 20W14L 24W22L 24W20L 24W18L 16” 18” 20” 16” 18” 20” 22” 14” 24” 22” 2 POINT Mounting Hardware Only 4 POINT Only VB-BS Sizes available are subject to hardware being used. IF DESIRED SIZE IS NOT LISTED, PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248 VISCO-BACK ® ORDER FORM Patient Reference: PAGE 1 of 4 Required COVER & HARDWARE SELECTION 2 Required 2.1 COVER SELECTION MSRP $0.00 Both fabrics are latex-free. Fabric selection is for the support surface only. Other fabrics used in cover construction remain the same. COMFORT-TEK™ Cover (COMFORT-TEK) STRETCH-AIR™ Cover (STRETCH-AIR) QUICK RELEASE 2 POINT (Q-COMPASS) QUICK RELEASE 4 POINT (Q-COMPASS4) COMFORT-TEK™ is a smooth, easily cleaned surface. The fluid protection aids in infection control. STRETCH-AIR™ has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant. Please fill in the above with dimensions from the size chart to the right. Example Part: VB-BS16W18L 2.2 HARDWARE SELECTION MSRP $0.00 COMPASS ® 4 QUICK RELEASE 4 POINT TOP VIEW FOR 16W-22W FOR 24W 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 1.406.522.8563.
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SIZE SELECTION1
LEN
GTH
*
FRAME WIDTH
16”
18”
20”
16” 18” 20” 22”
14”
24”
22”
VISCO BACK®
ORDER FORMHCPCS CODING: E2611/E2612
GENERAL USE BACK
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
$514.00 $590.00
$439.00 $514.00
Shown with Compass® 4 Quick Release 2 Point Hardware.
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
BASE MSRP BY SIZE
VIS
CO
-BA
CK
-OR
DE
R R
EV
0316
LEN
GTH
*
FRAME WIDTH
16W22L 18W22L 20W22L 22W22L
16W20L 18W20L 20W20L 22W20L
16W18L 18W18L 20W18L 22W18L
16W16L 18W16L 20W16L 22W16L
16W14L 18W14L 20W14L
24W22L
24W20L
24W18L
16”
18”
20”
16” 18” 20” 22”
14”
24”
22”
2 POINT Mounting Hardware Only 4 POINT Only
VB-BSSizes available are subject to hardware being used. IF DESIRED SIZE IS NOT LISTED, PLEASE CONTACT
CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248
VISCO-BACK® ORDER FORM Patient Reference: PAGE 1 of 4
Required
COVER & HARDWARE SELECTION2 Required
2.1 COVER SELECTIONMSRP $0.00
Both fabrics are latex-free. Fabric selection is for the support surface only. Other fabrics used in cover construction remain the same.
COMFORT-TEK™ Cover(COMFORT-TEK)
STRETCH-AIR™ Cover (STRETCH-AIR)
QUICK RELEASE 2 POINT (Q-COMPASS)
QUICK RELEASE 4 POINT(Q-COMPASS4)
COMFORT-TEK™ is a smooth, easily cleaned surface. The fluid
protection aids in infection control.
STRETCH-AIR™ has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant.
Please fill in the above with dimensions from the size chart to the right.Example Part: VB-BS16W18L
2.2 HARDWARE SELECTIONMSRP $0.00
COMPASS® 4 QUICK RELEASE
4 POINTTOP VIEW
FOR 16W-22W FOR 24W
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 1.406.522.8563.
VISCO-BACK® ORDER FORM Patient Reference: PAGE 2 of 4
Accent colors are applied via colored piping. Placement of the piping may vary by back support size and mounting hardware. If no colors are selected, our standard silver reflective piping is used at no additional cost.
This flap connects with hook & loop attachment between the seat and back for added privacy.
Privacy Flap
Color Location
RED (RED)
PURPLE (PURPLE)
PINK (PINK)
BLUE (BLUE)
GREEN (GREEN)
REMOVE (REMOVE)
PRIVACY FLAP (PV-FLAP)
A. THREAD COLOR OPTIONS
RED (EMB-RED) BLUE (EMB-BLUE)
PURPLE (EMB-PURPLE) GREEN (EMB-GREEN)
PINK (EMB-PINK) SILVER (EMB-SILVER)
B. FONT OPTIONS
Helvetica (EMB-Helvetica) (EMB-Twilight)
Garamond (EMB-Garamond) (EMB-Script)
C. WORD ONE
WORD TWO (optional)
*ADDITIONAL LEAD TIMES MAY APPLY
LATERAL TRUNK SUPPORT & HARDWARE4 Optional
4.1 LATERAL TRUNK SUPPORT PAD STYLE Select a left and/or right lateral trunk support pad using any combination of size, style and fabric.
STRETCH-AIR™
COMFORT-TEK™
has comfortable stretch, air transmission and heat
dissipation.
is a smooth, easily cleaned surface. The fluid protection
aids in infection control.
Contact Customer Service for custom sizes that are not listed below. 1.800.564.9248.HCPCS Code: E0956 MSRP $79.00/ea.
*Length (L) refers to the actual size dimension of the support from top to bottom edge.
L
D
L
D
L
D
L
D
MOLDABLE
RIGID
MOLDABLE ACTIVE
RIGID ACTIVE
4”D x 3”L 5”D x 3”L 5”D x 4”L 6”D x 4”L 6”D x 6”L 7”D x 5”L