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EMBRACE ATI ORDER FORM Patient Reference: PAGE 1 of 8
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
$450.00
$450.00
$498.00
$498.00
SIZE & STYLE1
ACTA-EMBRACE® ATI ORDER FORMHCPCS CODING: E2624/E2625ADJUSTABLE SKIN PROTECTION & POSITIONING SEAT CUSHION
Acta-Embrace™ ATI Zero Elevation shown with GlideWear®
ATI - Adjustable Technology Insert
Acta-Embrace™ ATI Anti-Thrust
DEP
THD
EPTH
WIDTH
WIDTH
EM-SZM-1824 EM-SZM-1924 EM-SZM-2024 EM-SZM-2124 EM-SZM-2224 EM-SZM-2324 EM-SZM-2424
EM-SZM-1823 EM-SZM-1923 EM-SZM-2023 EM-SZM-2123 EM-SZM-2223 EM-SZM-2323 EM-SZM-2423
EM-SZM-1622 EM-SZM-1722 EM-SZM-1822 EM-SZM-1922 EM-SZM-2022 EM-SZM-2122 EM-SZM-2222 EM-SZM-2322 EM-SZM-2422
EM-SZM-1521 EM-SZM-1621 EM-SZM-1721 EM-SZM-1821 EM-SZM-1921 EM-SZM-2021 EM-SZM-2121 EM-SZM-2221 EM-SZM-2321 EM-SZM-2421
EM-SZM-1420 EM-SZM-1520 EM-SZM-1620 EM-SZM-1720 EM-SZM-1820 EM-SZM-1920 EM-SZM-2020 EM-SZM-2120 EM-SZM-2220 EM-SZM-2320 EM-SZM-2420
EM-SZM-1419 EM-SZM-1519 EM-SZM-1619 EM-SZM-1719 EM-SZM-1819 EM-SZM-1919 EM-SZM-2019 EM-SZM-2119 EM-SZM-2219 EM-SZM-2319 EM-SZM-2419
EM-SZM-1218 EM-SZM-1318 EM-SZM-1418 EM-SZM-1518 EM-SZM-1618 EM-SZM-1718 EM-SZM-1818 EM-SZM-1918 EM-SZM-2018 EM-SZM-2118 EM-SZM-2218 EM-SZM-2318 EM-SZM-2418
EM-SZM-1117 EM-SZM-1217 EM-SZM-1317 EM-SZM-1417 EM-SZM-1517 EM-SZM-1617 EM-SZM-1717 EM-SZM-1817 EM-SZM-1917 EM-SZM-2017 EM-SZM-2117 EM-SZM-2217 EM-SZM-2317 EM-SZM-2417
EM-SZM-1016 EM-SZM-1116 EM-SZM-1216 EM-SZM-1316 EM-SZM-1416 EM-SZM-1516 EM-SZM-1616 EM-SZM-1716 EM-SZM-1816 EM-SZM-1916 EM-SZM-2016 EM-SZM-2116 EM-SZM-2216 EM-SZM-2316 EM-SZM-2416
EM-SZM-1015 EM-SZM-1115 EM-SZM-1215 EM-SZM-1315 EM-SZM-1415 EM-SZM-1515 EM-SZM-1615 EM-SZM-1715 EM-SZM-1815 EM-SZM-1915 EM-SZM-2015
EM-SZM-1014 EM-SZM-1114 EM-SZM-1214 EM-SZM-1314 EM-SZM-1414 EM-SZM-1514 EM-SZM-1614 EM-SZM-1714 EM-SZM-1814 EM-SZM-1914
EM-SZM-1013 EM-SZM-1113 EM-SZM-1213 EM-SZM-1313 EM-SZM-1413 EM-SZM-1513 EM-SZM-1613 EM-SZM-1713
EM-SZM-1012 EM-SZM-1112 EM-SZM-1212 EM-SZM-1312 EM-SZM-1412 EM-SZM-1512 EM-SZM-1612 EM-SZM-1712
EM-SZM-1011 EM-SZM-1111 EM-SZM-1211 EM-SZM-1311 EM-SZM-1411 EM-SZM-1511
EM-SZM-1010 EM-SZM-1110 EM-SZM-1210 EM-SZM-1310 EM-SZM-1410 EM-SZM-1510
EM-FZM-1824 EM-FZM-1924 EM-FZM-2024 EM-FZM-2124 EM-FZM-2224 EM-FZM-2324 EM-FZM-2424
EM-FZM-1823 EM-FZM-1923 EM-FZM-2023 EM-FZM-2123 EM-FZM-2223 EM-FZM-2323 EM-FZM-2423
EM-FZM-1622 EM-FZM-1722 EM-FZM-1822 EM-FZM-1922 EM-FZM-2022 EM-FZM-2122 EM-FZM-2222 EM-FZM-2322 EM-FZM-2422
EM-FZM-1521 EM-FZM-1621 EM-FZM-1721 EM-FZM-1821 EM-FZM-1921 EM-FZM-2021 EM-FZM-2121 EM-FZM-2221 EM-FZM-2321 EM-FZM-2421
EM-FZM-1420 EM-FZM-1520 EM-FZM-1620 EM-FZM-1720 EM-FZM-1820 EM-FZM-1920 EM-FZM-2020 EM-FZM-2120 EM-FZM-2220 EM-FZM-2320 EM-FZM-2420
EM-FZM-1419 EM-FZM-1519 EM-FZM-1619 EM-FZM-1719 EM-FZM-1819 EM-FZM-1919 EM-FZM-2019 EM-FZM-2119 EM-FZM-2219 EM-FZM-2319 EM-FZM-2419
EM-FZM-1218 EM-FZM-1318 EM-FZM-1418 EM-FZM-1518 EM-FZM-1618 EM-FZM-1718 EM-FZM-1818 EM-FZM-1918 EM-FZM-2018 EM-FZM-2118 EM-FZM-2218 EM-FZM-2318 EM-FZM-2418
EM-FZM-1117 EM-FZM-1217 EM-FZM-1317 EM-FZM-1417 EM-FZM-1517 EM-FZM-1617 EM-FZM-1717 EM-FZM-1817 EM-FZM-1917 EM-FZM-2017 EM-FZM-2117 EM-FZM-2217 EM-FZM-2317 EM-FZM-2417
EM-FZM-1016 EM-FZM-1116 EM-FZM-1216 EM-FZM-1316 EM-FZM-1416 EM-FZM-1516 EM-FZM-1616 EM-FZM-1716 EM-FZM-1816 EM-FZM-1916 EM-FZM-2016 EM-FZM-2116 EM-FZM-2216 EM-FZM-2316 EM-FZM-2416
EM-FZM-1015 EM-FZM-1115 EM-FZM-1215 EM-FZM-1315 EM-FZM-1415 EM-FZM-1515 EM-FZM-1615 EM-FZM-1715 EM-FZM-1815 EM-FZM-1915 EM-FZM-2015
EM-FZM-1014 EM-FZM-1114 EM-FZM-1214 EM-FZM-1314 EM-FZM-1414 EM-FZM-1514 EM-FZM-1614 EM-FZM-1714 EM-FZM-1814 EM-FZM-1914
EM-FZM-1013 EM-FZM-1113 EM-FZM-1213 EM-FZM-1313 EM-FZM-1413 EM-FZM-1513 EM-FZM-1613 EM-FZM-1713
EM-FZM-1012 EM-FZM-1112 EM-FZM-1212 EM-FZM-1312 EM-FZM-1412 EM-FZM-1512 EM-FZM-1612 EM-FZM-1712
EM-FZM-1011 EM-FZM-1111 EM-FZM-1211 EM-FZM-1311 EM-FZM-1411 EM-FZM-1511
EM-FZM-1010 EM-FZM-1110 EM-FZM-1210 EM-FZM-1310 EM-FZM-1410 EM-FZM-1510
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STRETCH-AIR™
COMFORT-TEK™
ZERO ELEVATION Please select size in the appropriate fabric chart below.
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.*
ORCOMFORT-TEK™
FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.
STRETCH-AIR™FOR PATIENT COMFORT
& HEAT DISSIPATION.
EMBRACE ATI ORDER FORM Patient Reference: PAGE 2 of 8
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
$488.00
$488.00
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$536.00
DEP
THD
EPTH
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WIDTH
EM-SQZM-1824 EM-SQZM-1924 EM-SQZM-2024 EM-SQZM-2124 EM-SQZM-2224 EM-SQZM-2324 EM-SQZM-2424
EM-SQZM-1823 EM-SQZM-1923 EM-SQZM-2023 EM-SQZM-2123 EM-SQZM-2223 EM-SQZM-2323 EM-SQZM-2423
EM-SQZM-1622 EM-SQZM-1722 EM-SQZM-1822 EM-SQZM-1922 EM-SQZM-2022 EM-SQZM-2122 EM-SQZM-2222 EM-SQZM-2322 EM-SQZM-2422
EM-SQZM-1521 EM-SQZM-1621 EM-SQZM-1721 EM-SQZM-1821 EM-SQZM-1921 EM-SQZM-2021 EM-SQZM-2121 EM-SQZM-2221 EM-SQZM-2321 EM-SQZM-2421
EM-SQZM-1420 EM-SQZM-1520 EM-SQZM-1620 EM-SQZM-1720 EM-SQZM-1820 EM-SQZM-1920 EM-SQZM-2020 EM-SQZM-2120 EM-SQZM-2220 EM-SQZM-2320 EM-SQZM-2420
EM-SQZM-1419 EM-SQZM-1519 EM-SQZM-1619 EM-SQZM-1719 EM-SQZM-1819 EM-SQZM-1919 EM-SQZM-2019 EM-SQZM-2119 EM-SQZM-2219 EM-SQZM-2319 EM-SQZM-2419
EM-SQZM-1218 EM-SQZM-1318 EM-SQZM-1418 EM-SQZM-1518 EM-SQZM-1618 EM-SQZM-1718 EM-SQZM-1818 EM-SQZM-1918 EM-SQZM-2018 EM-SQZM-2118 EM-SQZM-2218 EM-SQZM-2318 EM-SQZM-2418
EM-SQZM-1117 EM-SQZM-1217 EM-SQZM-1317 EM-SQZM-1417 EM-SQZM-1517 EM-SQZM-1617 EM-SQZM-1717 EM-SQZM-1817 EM-SQZM-1917 EM-SQZM-2017 EM-SQZM-2117 EM-SQZM-2217 EM-SQZM-2317 EM-SQZM-2417
EM-SQZM-1016 EM-SQZM-1116 EM-SQZM-1216 EM-SQZM-1316 EM-SQZM-1416 EM-SQZM-1516 EM-SQZM-1616 EM-SQZM-1716 EM-SQZM-1816 EM-SQZM-1916 EM-SQZM-2016 EM-SQZM-2116 EM-SQZM-2216 EM-SQZM-2316 EM-SQZM-2416
EM-SQZM-1015 EM-SQZM-1115 EM-SQZM-1215 EM-SQZM-1315 EM-SQZM-1415 EM-SQZM-1515 EM-SQZM-1615 EM-SQZM-1715 EM-SQZM-1815 EM-SQZM-1915 EM-SQZM-2015
EM-SQZM-1014 EM-SQZM-1114 EM-SQZM-1214 EM-SQZM-1314 EM-SQZM-1414 EM-SQZM-1514 EM-SQZM-1614 EM-SQZM-1714 EM-SQZM-1814 EM-SQZM-1914
EM-SQZM-1013 EM-SQZM-1113 EM-SQZM-1213 EM-SQZM-1313 EM-SQZM-1413 EM-SQZM-1513 EM-SQZM-1613 EM-SQZM-1713
EM-SQZM-1012 EM-SQZM-1112 EM-SQZM-1212 EM-SQZM-1312 EM-SQZM-1412 EM-SQZM-1512 EM-SQZM-1612 EM-SQZM-1712
EM-SQZM-1011 EM-SQZM-1111 EM-SQZM-1211 EM-SQZM-1311 EM-SQZM-1411 EM-SQZM-1511
EM-SQZM-1010 EM-SQZM-1110 EM-SQZM-1210 EM-SQZM-1310 EM-SQZM-1410 EM-SQZM-1510
EM-FQZM-1824 EM-FQZM-1924 EM-FQZM-2024 EM-FQZM-2124 EM-FQZM-2224 EM-FQZM-2324 EM-FQZM-2424
EM-FQZM-1823 EM-FQZM-1923 EM-FQZM-2023 EM-FQZM-2123 EM-FQZM-2223 EM-FQZM-2323 EM-FQZM-2423
EM-FQZM-1622 EM-FQZM-1722 EM-FQZM-1822 EM-FQZM-1922 EM-FQZM-2022 EM-FQZM-2122 EM-FQZM-2222 EM-FQZM-2322 EM-FQZM-2422
EM-FQZM-1521 EM-FQZM-1621 EM-FQZM-1721 EM-FQZM-1821 EM-FQZM-1921 EM-FQZM-2021 EM-FQZM-2121 EM-FQZM-2221 EM-FQZM-2321 EM-FQZM-2421
EM-FQZM-1420 EM-FQZM-1520 EM-FQZM-1620 EM-FQZM-1720 EM-FQZM-1820 EM-FQZM-1920 EM-FQZM-2020 EM-FQZM-2120 EM-FQZM-2220 EM-FQZM-2320 EM-FQZM-2420
EM-FQZM-1419 EM-FQZM-1519 EM-FQZM-1619 EM-FQZM-1719 EM-FQZM-1819 EM-FQZM-1919 EM-FQZM-2019 EM-FQZM-2119 EM-FQZM-2219 EM-FQZM-2319 EM-FQZM-2419
EM-FQZM-1218 EM-FQZM-1318 EM-FQZM-1418 EM-FQZM-1518 EM-FQZM-1618 EM-FQZM-1718 EM-FQZM-1818 EM-FQZM-1918 EM-FQZM-2018 EM-FQZM-2118 EM-FQZM-2218 EM-FQZM-2318 EM-FQZM-2418
EM-FQZM-1117 EM-FQZM-1217 EM-FQZM-1317 EM-FQZM-1417 EM-FQZM-1517 EM-FQZM-1617 EM-FQZM-1717 EM-FQZM-1817 EM-FQZM-1917 EM-FQZM-2017 EM-FQZM-2117 EM-FQZM-2217 EM-FQZM-2317 EM-FQZM-2417
EM-FQZM-1016 EM-FQZM-1116 EM-FQZM-1216 EM-FQZM-1316 EM-FQZM-1416 EM-FQZM-1516 EM-FQZM-1616 EM-FQZM-1716 EM-FQZM-1816 EM-FQZM-1916 EM-FQZM-2016 EM-FQZM-2116 EM-FQZM-2216 EM-FQZM-2316 EM-FQZM-2416
EM-FQZM-1015 EM-FQZM-1115 EM-FQZM-1215 EM-FQZM-1315 EM-FQZM-1415 EM-FQZM-1515 EM-FQZM-1615 EM-FQZM-1715 EM-FQZM-1815 EM-FQZM-1915 EM-FQZM-2015
EM-FQZM-1014 EM-FQZM-1114 EM-FQZM-1214 EM-FQZM-1314 EM-FQZM-1414 EM-FQZM-1514 EM-FQZM-1614 EM-FQZM-1714 EM-FQZM-1814 EM-FQZM-1914
EM-FQZM-1013 EM-FQZM-1113 EM-FQZM-1213 EM-FQZM-1313 EM-FQZM-1413 EM-FQZM-1513 EM-FQZM-1613 EM-FQZM-1713
EM-FQZM-1012 EM-FQZM-1112 EM-FQZM-1212 EM-FQZM-1312 EM-FQZM-1412 EM-FQZM-1512 EM-FQZM-1612 EM-FQZM-1712
EM-FQZM-1011 EM-FQZM-1111 EM-FQZM-1211 EM-FQZM-1311 EM-FQZM-1411 EM-FQZM-1511
EM-FQZM-1010 EM-FQZM-1110 EM-FQZM-1210 EM-FQZM-1310 EM-FQZM-1410 EM-FQZM-1510
21”
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19”
12”
12”
18”
18”
11”
11”
10”
10”
24”
24”
17”
17”
STRETCH-AIR™ with GLIDEWEAR®
COMFORT-TEK™ with GLIDEWEAR®
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
ZERO ELEVATION withPlease select size in the appropriate fabric chart below.
ORCOMFORT-TEK™
FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.
STRETCH-AIR™FOR PATIENT COMFORT
& HEAT DISSIPATION.
EMBRACE ATI ORDER FORM Patient Reference: PAGE 3 of 8
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
$450.00
$450.00
$498.00
$498.00
DEP
THD
EPTH
WIDTH
WIDTH
EM-SAM-1824 EM-SAM-1924 EM-SAM-2024 EM-SAM-2124 EM-SAM-2224 EM-SAM-2324 EM-SAM-2424
EM-SAM-1823 EM-SAM-1923 EM-SAM-2023 EM-SAM-2123 EM-SAM-2223 EM-SAM-2323 EM-SAM-2423
EM-SAM-1622 EM-SAM-1722 EM-SAM-1822 EM-SAM-1922 EM-SAM-2022 EM-SAM-2122 EM-SAM-2222 EM-SAM-2322 EM-SAM-2422
EM-SAM-1521 EM-SAM-1621 EM-SAM-1721 EM-SAM-1821 EM-SAM-1921 EM-SAM-2021 EM-SAM-2121 EM-SAM-2221 EM-SAM-2321 EM-SAM-2421
EM-SAM-1420 EM-SAM-1520 EM-SAM-1620 EM-SAM-1720 EM-SAM-1820 EM-SAM-1920 EM-SAM-2020 EM-SAM-2120 EM-SAM-2220 EM-SAM-2320 EM-SAM-2420
EM-SAM-1419 EM-SAM-1519 EM-SAM-1619 EM-SAM-1719 EM-SAM-1819 EM-SAM-1919 EM-SAM-2019 EM-SAM-2119 EM-SAM-2219 EM-SAM-2319 EM-SAM-2419
EM-SAM-1218 EM-SAM-1318 EM-SAM-1418 EM-SAM-1518 EM-SAM-1618 EM-SAM-1718 EM-SAM-1818 EM-SAM-1918 EM-SAM-2018 EM-SAM-2118 EM-SAM-2218 EM-SAM-2318 EM-SAM-2418
EM-SAM-1117 EM-SAM-1217 EM-SAM-1317 EM-SAM-1417 EM-SAM-1517 EM-SAM-1617 EM-SAM-1717 EM-SAM-1817 EM-SAM-1917 EM-SAM-2017 EM-SAM-2117 EM-SAM-2217 EM-SAM-2317 EM-SAM-2417
EM-SAM-1016 EM-SAM-1116 EM-SAM-1216 EM-SAM-1316 EM-SAM-1416 EM-SAM-1516 EM-SAM-1616 EM-SAM-1716 EM-SAM-1816 EM-SAM-1916 EM-SAM-2016 EM-SAM-2116 EM-SAM-2216 EM-SAM-2316 EM-SAM-2416
EM-SAM-1015 EM-SAM-1115 EM-SAM-1215 EM-SAM-1315 EM-SAM-1415 EM-SAM-1515 EM-SAM-1615 EM-SAM-1715 EM-SAM-1815 EM-SAM-1915 EM-SAM-2015
EM-SAM-1014 EM-SAM-1114 EM-SAM-1214 EM-SAM-1314 EM-SAM-1414 EM-SAM-1514 EM-SAM-1614 EM-SAM-1714 EM-SAM-1814 EM-SAM-1914
EM-SAM-1013 EM-SAM-1113 EM-SAM-1213 EM-SAM-1313 EM-SAM-1413 EM-SAM-1513 EM-SAM-1613 EM-SAM-1713
EM-SAM-1012 EM-SAM-1112 EM-SAM-1212 EM-SAM-1312 EM-SAM-1412 EM-SAM-1512 EM-SAM-1612 EM-SAM-1712
EM-SAM-1011 EM-SAM-1111 EM-SAM-1211 EM-SAM-1311 EM-SAM-1411 EM-SAM-1511
EM-SAM-1010 EM-SAM-1110 EM-SAM-1210 EM-SAM-1310 EM-SAM-1410 EM-SAM-1510
EM-FAM-1824 EM-FAM-1924 EM-FAM-2024 EM-FAM-2124 EM-FAM-2224 EM-FAM-2324 EM-FAM-2424
EM-FAM-1823 EM-FAM-1923 EM-FAM-2023 EM-FAM-2123 EM-FAM-2223 EM-FAM-2323 EM-FAM-2423
EM-FAM-1622 EM-FAM-1722 EM-FAM-1822 EM-FAM-1922 EM-FAM-2022 EM-FAM-2122 EM-FAM-2222 EM-FAM-2322 EM-FAM-2422
EM-FAM-1521 EM-FAM-1621 EM-FAM-1721 EM-FAM-1821 EM-FAM-1921 EM-FAM-2021 EM-FAM-2121 EM-FAM-2221 EM-FAM-2321 EM-FAM-2421
EM-FAM-1420 EM-FAM-1520 EM-FAM-1620 EM-FAM-1720 EM-FAM-1820 EM-FAM-1920 EM-FAM-2020 EM-FAM-2120 EM-FAM-2220 EM-FAM-2320 EM-FAM-2420
EM-FAM-1419 EM-FAM-1519 EM-FAM-1619 EM-FAM-1719 EM-FAM-1819 EM-FAM-1919 EM-FAM-2019 EM-FAM-2119 EM-FAM-2219 EM-FAM-2319 EM-FAM-2419
EM-FAM-1218 EM-FAM-1318 EM-FAM-1418 EM-FAM-1518 EM-FAM-1618 EM-FAM-1718 EM-FAM-1818 EM-FAM-1918 EM-FAM-2018 EM-FAM-2118 EM-FAM-2218 EM-FAM-2318 EM-FAM-2418
EM-FAM-1117 EM-FAM-1217 EM-FAM-1317 EM-FAM-1417 EM-FAM-1517 EM-FAM-1617 EM-FAM-1717 EM-FAM-1817 EM-FAM-1917 EM-FAM-2017 EM-FAM-2117 EM-FAM-2217 EM-FAM-2317 EM-FAM-2417
EM-FAM-1016 EM-FAM-1116 EM-FAM-1216 EM-FAM-1316 EM-FAM-1416 EM-FAM-1516 EM-FAM-1616 EM-FAM-1716 EM-FAM-1816 EM-FAM-1916 EM-FAM-2016 EM-FAM-2116 EM-FAM-2216 EM-FAM-2316 EM-FAM-2416
EM-FAM-1015 EM-FAM-1115 EM-FAM-1215 EM-FAM-1315 EM-FAM-1415 EM-FAM-1515 EM-FAM-1615 EM-FAM-1715 EM-FAM-1815 EM-FAM-1915 EM-FAM-2015
EM-FAM-1014 EM-FAM-1114 EM-FAM-1214 EM-FAM-1314 EM-FAM-1414 EM-FAM-1514 EM-FAM-1614 EM-FAM-1714 EM-FAM-1814 EM-FAM-1914
EM-FAM-1013 EM-FAM-1113 EM-FAM-1213 EM-FAM-1313 EM-FAM-1413 EM-FAM-1513 EM-FAM-1613 EM-FAM-1713
EM-FAM-1012 EM-FAM-1112 EM-FAM-1212 EM-FAM-1312 EM-FAM-1412 EM-FAM-1512 EM-FAM-1612 EM-FAM-1712
EM-FAM-1011 EM-FAM-1111 EM-FAM-1211 EM-FAM-1311 EM-FAM-1411 EM-FAM-1511
EM-FAM-1010 EM-FAM-1110 EM-FAM-1210 EM-FAM-1310 EM-FAM-1410 EM-FAM-1510
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10”
10”
24”
24”
17”
17”
STRETCH-AIR™
COMFORT-TEK™
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.736.0925
ANTI-THRUSTPlease select size in the appropriate fabric chart below.
ORCOMFORT-TEK™
FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.
STRETCH-AIR™FOR PATIENT COMFORT
& HEAT DISSIPATION.
EMBRACE ATI ORDER FORM Patient Reference: PAGE 4 of 8
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
$488.00
$488.00
$536.00
$536.00
DEP
THD
EPTH
WIDTH
WIDTH
EM-SQAM-1824 EM-SQAM-1924 EM-SQAM-2024 EM-SQAM-2124 EM-SQAM-2224 EM-SQAM-2324 EM-SQAM-2424
EM-SQAM-1823 EM-SQAM-1923 EM-SQAM-2023 EM-SQAM-2123 EM-SQAM-2223 EM-SQAM-2323 EM-SQAM-2423
EM-SQAM-1622 EM-SQAM-1722 EM-SQAM-1822 EM-SQAM-1922 EM-SQAM-2022 EM-SQAM-2122 EM-SQAM-2222 EM-SQAM-2322 EM-SQAM-2422
EM-SQAM-1521 EM-SQAM-1621 EM-SQAM-1721 EM-SQAM-1821 EM-SQAM-1921 EM-SQAM-2021 EM-SQAM-2121 EM-SQAM-2221 EM-SQAM-2321 EM-SQAM-2421
EM-SQAM-1420 EM-SQAM-1520 EM-SQAM-1620 EM-SQAM-1720 EM-SQAM-1820 EM-SQAM-1920 EM-SQAM-2020 EM-SQAM-2120 EM-SQAM-2220 EM-SQAM-2320 EM-SQAM-2420
EM-SQAM-1419 EM-SQAM-1519 EM-SQAM-1619 EM-SQAM-1719 EM-SQAM-1819 EM-SQAM-1919 EM-SQAM-2019 EM-SQAM-2119 EM-SQAM-2219 EM-SQAM-2319 EM-SQAM-2419
EM-SQAM-1218 EM-SQAM-1318 EM-SQAM-1418 EM-SQAM-1518 EM-SQAM-1618 EM-SQAM-1718 EM-SQAM-1818 EM-SQAM-1918 EM-SQAM-2018 EM-SQAM-2118 EM-SQAM-2218 EM-SQAM-2318 EM-SQAM-2418
EM-SQAM-1117 EM-SQAM-1217 EM-SQAM-1317 EM-SQAM-1417 EM-SQAM-1517 EM-SQAM-1617 EM-SQAM-1717 EM-SQAM-1817 EM-SQAM-1917 EM-SQAM-2017 EM-SQAM-2117 EM-SQAM-2217 EM-SQAM-2317 EM-SQAM-2417
EM-SQAM-1016 EM-SQAM-1116 EM-SQAM-1216 EM-SQAM-1316 EM-SQAM-1416 EM-SQAM-1516 EM-SQAM-1616 EM-SQAM-1716 EM-SQAM-1816 EM-SQAM-1916 EM-SQAM-2016 EM-SQAM-2116 EM-SQAM-2216 EM-SQAM-2316 EM-SQAM-2416
EM-SQAM-1015 EM-SQAM-1115 EM-SQAM-1215 EM-SQAM-1315 EM-SQAM-1415 EM-SQAM-1515 EM-SQAM-1615 EM-SQAM-1715 EM-SQAM-1815 EM-SQAM-1915 EM-SQAM-2015
EM-SQAM-1014 EM-SQAM-1114 EM-SQAM-1214 EM-SQAM-1314 EM-SQAM-1414 EM-SQAM-1514 EM-SQAM-1614 EM-SQAM-1714 EM-SQAM-1814 EM-SQAM-1914
EM-SQAM-1013 EM-SQAM-1113 EM-SQAM-1213 EM-SQAM-1313 EM-SQAM-1413 EM-SQAM-1513 EM-SQAM-1613 EM-SQAM-1713
EM-SQAM-1012 EM-SQAM-1112 EM-SQAM-1212 EM-SQAM-1312 EM-SQAM-1412 EM-SQAM-1512 EM-SQAM-1612 EM-SQAM-1712
EM-SQAM-1011 EM-SQAM-1111 EM-SQAM-1211 EM-SQAM-1311 EM-SQAM-1411 EM-SQAM-1511
EM-SQAM-1010 EM-SQAM-1110 EM-SQAM-1210 EM-SQAM-1310 EM-SQAM-1410 EM-SQAM-1510
EM-FQAM-1824 EM-FQAM-1924 EM-FQAM-2024 EM-FQAM-2124 EM-FQAM-2224 EM-FQAM-2324 EM-FQAM-2424
EM-FQAM-1823 EM-FQAM-1923 EM-FQAM-2023 EM-FQAM-2123 EM-FQAM-2223 EM-FQAM-2323 EM-FQAM-2423
EM-FQAM-1622 EM-FQAM-1722 EM-FQAM-1822 EM-FQAM-1922 EM-FQAM-2022 EM-FQAM-2122 EM-FQAM-2222 EM-FQAM-2322 EM-FQAM-2422
EM-FQAM-1521 EM-FQAM-1621 EM-FQAM-1721 EM-FQAM-1821 EM-FQAM-1921 EM-FQAM-2021 EM-FQAM-2121 EM-FQAM-2221 EM-FQAM-2321 EM-FQAM-2421
EM-FQAM-1420 EM-FQAM-1520 EM-FQAM-1620 EM-FQAM-1720 EM-FQAM-1820 EM-FQAM-1920 EM-FQAM-2020 EM-FQAM-2120 EM-FQAM-2220 EM-FQAM-2320 EM-FQAM-2420
EM-FQAM-1419 EM-FQAM-1519 EM-FQAM-1619 EM-FQAM-1719 EM-FQAM-1819 EM-FQAM-1919 EM-FQAM-2019 EM-FQAM-2119 EM-FQAM-2219 EM-FQAM-2319 EM-FQAM-2419
EM-FQAM-1218 EM-FQAM-1318 EM-FQAM-1418 EM-FQAM-1518 EM-FQAM-1618 EM-FQAM-1718 EM-FQAM-1818 EM-FQAM-1918 EM-FQAM-2018 EM-FQAM-2118 EM-FQAM-2218 EM-FQAM-2318 EM-FQAM-2418
EM-FQAM-1117 EM-FQAM-1217 EM-FQAM-1317 EM-FQAM-1417 EM-FQAM-1517 EM-FQAM-1617 EM-FQAM-1717 EM-FQAM-1817 EM-FQAM-1917 EM-FQAM-2017 EM-FQAM-2117 EM-FQAM-2217 EM-FQAM-2317 EM-FQAM-2417
EM-FQAM-1016 EM-FQAM-1116 EM-FQAM-1216 EM-FQAM-1316 EM-FQAM-1416 EM-FQAM-1516 EM-FQAM-1616 EM-FQAM-1716 EM-FQAM-1816 EM-FQAM-1916 EM-FQAM-2016 EM-FQAM-2116 EM-FQAM-2216 EM-FQAM-2316 EM-FQAM-2416
EM-FQAM-1015 EM-FQAM-1115 EM-FQAM-1215 EM-FQAM-1315 EM-FQAM-1415 EM-FQAM-1515 EM-FQAM-1615 EM-FQAM-1715 EM-FQAM-1815 EM-FQAM-1915 EM-FQAM-2015
EM-FQAM-1014 EM-FQAM-1114 EM-FQAM-1214 EM-FQAM-1314 EM-FQAM-1414 EM-FQAM-1514 EM-FQAM-1614 EM-FQAM-1714 EM-FQAM-1814 EM-FQAM-1914
EM-FQAM-1013 EM-FQAM-1113 EM-FQAM-1213 EM-FQAM-1313 EM-FQAM-1413 EM-FQAM-1513 EM-FQAM-1613 EM-FQAM-1713
EM-FQAM-1012 EM-FQAM-1112 EM-FQAM-1212 EM-FQAM-1312 EM-FQAM-1412 EM-FQAM-1512 EM-FQAM-1612 EM-FQAM-1712
EM-FQAM-1011 EM-FQAM-1111 EM-FQAM-1211 EM-FQAM-1311 EM-FQAM-1411 EM-FQAM-1511
EM-FQAM-1010 EM-FQAM-1110 EM-FQAM-1210 EM-FQAM-1310 EM-FQAM-1410 EM-FQAM-1510
21”
21”
14”
14”
22”
22”
15”
15”
23”
23”
16”
16”
10”
10”
18”
18”
14”
14”
22”
22”
11”
11”
19”
19”
15”
15”
23”
23”
12”
12”
20”
20”
16”
16”
24”
24”
13”
13”
21”
21”
17”
17”
20”
20”
13”
13”
19”
19”
12”
12”
18”
18”
11”
11”
10”
10”
24”
24”
17”
17”
STRETCH-AIR™ with GLIDEWEAR®
COMFORT-TEK™ with GLIDEWEAR®
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
ANTI-THRUST withPlease select size in the appropriate fabric chart below.
ORCOMFORT-TEK™
FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.
STRETCH-AIR™FOR PATIENT COMFORT
& HEAT DISSIPATION.
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*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
B = 1” Rail Cut (RAIL-CUT-1.0)
B = 1½” Rail Cut (RAIL-CUT-1.5)
B = 2” Rail Cut (RAIL-CUT-2.0)
Solid Seat Pan & Hardware Kit(RSSP-N-HARD)
2.7REMOVABLE SOLID SEAT PAN & HARDWARE KITHCPCS Code: E2231 MSRP $387.00
Rigid Insert Glued(RGD-INSERT-GLUED)
Rigid Insert Not Glued(RGD-INSERT-UNGLUED)
2.8 RIGID INSERTHCPCS Code: E0992MSRP $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
C = 1” D (GROWTH-NOTCH-1)
C = 2” D (GROWTH-NOTCH-2)
C = 3” D (GROWTH-NOTCH-3)
C =Other(GROWTH-NOTCH-OTHER)
2.1 GROWTH NOTCHESMSRP $0.00
If growth notches are selected, a 1¼” wide cut will be taken from each side to allow the cushion to fit between the chair canes.
DEPTH OF NOTCHES
C
TOP VIEW
1¼”
2.5 INCONTINENCE LINERMSRP One = $60.00 - Two = $120.00
Liner provides extra incontinence protection for the cushion.
One Incontinence Liner (INCON-LINER)
Two Incontinence Liners (INCON-LINER)
2.6 EXTRA COVERMSRP One = $62.00 - Two = $124.00
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)
2.3COLOR - COMES STANDARD SILVER REFLECTIVE PIPINGMSRP $26.00
Accent colors can be applied to the cushion via colored piping. If no colors are selected, our standard silver reflective piping is used.
Red (RED) Blue (BLUE)
Purple (PURPLE) Green (GREEN)
Pink (PINK) Remove (REMOVE)
Orange (ORANGE)
COLOR LOCATION
2.2 RAIL CUTSMSRP $26.00
A standard 1 1/2” wide cut will be made and you decide how high the cut will need to be. All cuts run the entire depth of the cushion.
FRONT
B
1½”
Kwik Strap®
(KWIK-STRAP)
2.4 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
*All accessories are cosmetic changes to the cushion except for options in gray, which are add on items.
ACTA-EMBRACE™ ACCESSORIES
ZIPPERED POUCHMSRP $26.00
2.9
Zippered Pouch (ZIP-POUCH)
ZIPPERED POUCH
LOCATION
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*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
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*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
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*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
