ASR 2011 - .ASR 2011 Narrow $3988.52 ASR 2011 HD (Heavy Duty) $4,171.42 Custom Frame (call ... Animal

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Text of ASR 2011 - .ASR 2011 Narrow $3988.52 ASR 2011 HD (Heavy Duty) $4,171.42 Custom Frame (call ......

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    ASR 2011AGE: 10+ YEARS INSEAM: 19"+

    RIDER INFORMATION Male Female

    Riders Name: ____________________________________________________

    Date of Birth: MONTH ____________ /DAY ____________ /YEAR ___________

    Diagnosis: ________________________________________________________

    Weight: _______lbs. _______kgs. Height: _______inches _______cm

    A. Seat Depth: ________________ inches ___________ cm

    B. Inseam: __________________ inches

    _____________________ cm

    C. Back Height: _______________ inches

    __________________ cm

    D. Seat Width: _______________ inches ___________ cm

    THERAPISTS Name: ______________________________________________

    Phone: ___________________________________________________________

    Fax: ____________________________________________________________

    Email: ___________________________________________________________

    A

    C D

    B

    ASR 2011 Evaluation Form (Jan 19/16)

    PAGE SUB-TOTAL

    E. Total Length: 77" F. Rear steering allows bike to be

    controlled from the rear, this adds 12" to the length of the model.

    G. Width: 35"/31 (Narrow)H. Steering head tube

    unlocks/locks steering Transfer Height: 14

    F

    H

    E*Maximum Weight on Removable Rear Platform is 25 lbs.

    FRAME CHOICE

    (Not available with Rear Steering)

    CHAIN GUARD

    Heavy Duty Steel Chain Guard (std)

    TOTAL

    REAR STEERINGRear Steering

    PROPULSION

    NEW

    BOTTOM BRACKET WIDTHStandard Crank 6" Wide (std)

    Note: All devices can tip, but by narrowing the frame, the risk becomes greater. A waiver is always included with this bike.

    W E C A N C U S T O M B U I L D B A S E D O N Y O U R S P E C I F I C N E E D S !

    COLOR CHOICE

    Direct Drive (std)

    TEC Drive - 3-Speed Direct Drive

    Shift Lever Location RIGHT RS

    NEW

    NEW

    PEDAL POWER (For Single Speed only) Easy (n/c) Average (std) Challenging (n/c)

    Shorter range is suitable for limited knee flexion.

    I. 3" (79mm) x 26T Alloy Crank (n/c)

    J. 4 (102mm) x 32T Alloy Crank (n/c)

    K. 5 (127mm) x 32T Alloy Crank (STD)

    CRANK ARM LENGTHS - RANGE OF MOTION

    I J K L

    FORK

    Chrome Fork (std)Suspension Fork (Required when Disc Brakes are ordered)

    ASR 2011 (Includes std Bold Items) $3,748.77ASR 2011 Narrow $3988.52ASR 2011 HD (Heavy Duty) $4,171.42Custom Frame (call for price)

    Candy Blue Hot Rod Purple (std)

    Blue Red Yellow Pink

    Other Custom Color

    Please Specify: _____________________________

    Sticker Type Male FemalePlease note extra delivery time for non-standard & custom colors.

    Removable Rear Platform* (Required for Electric Assist) $368.15

    $570.59 Adjustable Jogging Extension Handle ADD $170.75

    Free Wheel

    Manual Free Wheel / Direct Drive Reciprocator System

    (eAsY, AVeRAge, chAllenging) R Rs

    REC - 2-Speed Direct Drive w/ Neutral(eAsY, AVeRAge, OFF) R Rs

    Thumb Shift Lever (STD)

    Nexus 8-Speed Drive

    Electric Assist

    L. Crank Shortener (reduces length by 1/2)

    Effective January 19, 2016 Page 1

    RehabmartTypewritten text$118.60

    RehabmartTypewritten text$254.96

    RehabmartTypewritten text$85.42

    RehabmartTypewritten text$219.58

    RehabmartTypewritten text$501.50

    RehabmartTypewritten text$501.50

    RehabmartTypewritten text$600.20

    RehabmartTypewritten text$1918.40

    RehabmartTypewritten text$144.71

    RehabmartTypewritten text$208.72

  • Creating a CYCLE of mobilityTM

    TIRESO. 20" Smooth (std)

    O

    NM

    P

    WHEELS

    PARKING BRAKE (transfer purposes)

    LEVER POSITIONING FRONT BRAKE REAR BRAKELeft Handlebar Right Handlebar Rear Assistance (T-bar) (n/A) (n/A)Rear Steering Handle

    BRAKE OPTIONSFRONT BRAKE REAR BRAKE

    Vee Brakes (std) Disc Brakes (std)

    BRAKE LEVER POSITION

    14

    158 9 10 11 12 13

    SEAT BASE

    BACK REST

    Chest Strap (High Back only) (std)

    18. Adult Xtended-High Back (17 width, 22 height)

    (Includes Custom Back) (2 Required for Set)

    A. chest WiDth ______ inches ______ cm b. seAt tO ARmpit ______ inches ______ cmCustom (call for price)

    A. ________ inches ________ cm B. ________ inches ________ cm

    NEW

    16

    AB17

    18

    19

    PEDALSMeasure Riders Shoe: i) _____ inches _____ cm ii) ______ inches ______ cm OR TRACE OUTLINE OF RIDERS SHOE ON A PIECE OF PAPER & SUBMIT w/ORDER.

    Please specify Left or Right

    5 76

    3 42

    ii

    i

    Shoe Heel Widest Point

    Shoe length

    1

    HEAD REST

    PLEASE NOTE: Required for addition of Adjustable Rain and Sun Shade Canopy

    21. Adjustable Velcro Occiput Support Cushion PLEASE NOTE: Includes Adjustable/Removable Headrest option.

    22. i2i Head & Neck Support System with Support Bracket PLEASE NOTE: Please specify size as per brochure.23. Headpod Support System with Support Bracket PLEASE NOTE: Includes Adjustable/Removable Headrest option.

    Custom - Custom Mount of Head Support Bracket (Template required) (call for price)

    height: ________ inches ________ cm WiDth: ________ inches ________ cm

    Adjustable Rain & Sun Shade Canopy PLEASE NOTE: Requires the Adjustable/Removable Headrest

    23222120

    HANDLE BARS Steering Locked Steering Unlocked

    R. High Rise (n/c) S. Wide (n/c)

    R ST

    i

    ii

    PAGE SUB-TOTAL

    NEW

    M. 20" Aluminum (std)20 HD Wheels (included on hD n/c) ($301.26)Removable Wheels N. Spoke Covers (set of three)

    P. 20" Knobby

    Parking Brake (Right Rear Wheel) (std)Second Parking Brake (Left Rear Wheel)

    Disc Brakes ($165.33) *Must have Suspension Fork Coaster($102.01) - Nexus 8-Speed Only -

    1. Mountain Style Pedal (std) 2. with Cage ($42.65)3. Neoprene Adjustable Footplate* S M L XL 4. Molded ABS Footplate System* XS S M L XL5. Molded ABS Footplates with Ratcheting Straps Size Options: XS S M L XL 6. Pulley System (FRONT: corrects plantar flexion) Pulley System (REAR: self-leveling pedals) 7. Abductor Leg Brace *requires #5 Molded ABS Footplate S M L

    0.25 Footplate Spacers Qty: ______/Pedal ($13.66/unit)

    T. Hoop (std)

    i. Bar End Extensions

    ii. Nameplate Special Dedication ($42.65) Company Logo($74.36)

    8. Child (12.5" width, 12.5" depth) (n/c)9. Child Narrow 10. Adult Seat (16.75" width, 14" depth) (std)11. Adult Narrow 12. Add 2" Raised Pommel to seat selection above 13. Custom (measurements) (call for price)A. ________ inches ________ cm B. ________ inches ________ cm14. Hip Belt, 2" wide (Large Size) (std)15. Neoprene Hip Stabilizer Belt

    16. Child High Back - (13" width, 18" height) 17. Adult High Back - (17 width, 18 height) (std)

    Effective January 19, 2016 Page 2

    20. Adjustable/Removable Headrest

    19. Lateral Support Bracket complete w/Track S L ($352.71/EA)

    RehabmartTypewritten text$301.26

    RehabmartTypewritten text$118.60

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$132.78

    RehabmartTypewritten text$332.13

    RehabmartTypewritten text$373.30

    RehabmartTypewritten text$457.08

    RehabmartTypewritten text$42.65

    RehabmartTypewritten text$42.65

    RehabmartTypewritten text($486.69/ea)

    RehabmartTypewritten text$72.15

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$192.45

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$107.54

    RehabmartTypewritten text$197.88

    RehabmartTypewritten text$342.43

    RehabmartTypewritten text$973.30

    RehabmartTypewritten text$674.22

    RehabmartTypewritten text$321.84

  • Creating a CYCLE of mobilityTM

    STATIONARY TRAINER

    Total - Page 3

    Total - Page 2

    Total - Page 1

    SUB-TOTAL

    TOTAL

    ABDUCTOR/ADDUCTION

    24 25

    GLOVES

    Hand Tracing RequiredB

    A

    _____ inches _____ cm

    B. Measure width of wrist _____ inches _____ cm

    C. Measure bend of wrist to top of middle finger _____ inches _____ cm

    C

    PRIVACY POLICYFreedom Concepts Inc. collects, uses and discloses personal information of the Customer and/or Rider to properly assemble and manufacture the mobility deviceand may contact the Riders therapist for additional personal information to assistwith this process. The collection, use and disclosure of the personal informationof the Customer and/or the Rider is governed by any consent which may, from timeto time, be provided, and by the Freedom Concepts Inc. Privacy Policy which isavailable on our website www.freedomconcepts.com or by contacting our office.By signing below, you hereby warrant that you have the authority to bind the Riderand hereby authorize the collection, use, and disclosure of personal information asherein provided and in accordance with the Freedom C