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G
ASR 2011AGE: 10+ YEARS INSEAM: 19"+
RIDER INFORMATION Male Female
Rider’s 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
THERAPIST’S 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
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 ______ cm
Custom (call for price)
A. ________ inches ________ cm B. ________ inches ________ cm
NEW
16
AB17
18
19
PEDALSMeasure Rider’s Shoe: i) _____ inches _____ cm ii) ______ inches ______ cm OR TRACE OUTLINE OF RIDER’S 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)
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 Rider’s 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 Concepts Inc. Privacy Policy.
TERMS & CONDITIONSPrices are subject to change without notice. Prepaid or net 30 days O.A.C.All taxes extra. Freight extra. Manufacturer reserves the right to change prices,colors, features, dates, locations and products without notice. Residentialdelivery charge may apply. Duty and brokerage included where applicable.
SIGNATURE OF RIDER/PARENT
I hereby give permission to Freedom Concepts Inc. to use photographs of me or my child for the sole purpose of the company’s promotional use, and will not be distributed to third parties. YES NOI would like to receive regular updates. SNAIL MAIL EMAIL NO
CUSTOMER SIGNATURE
CUSTOMER INFORMATIONDealer/Vendor: ______________________________________________________
Contact Person: _____________________________________________________
Address: ___________________________________________________________
City: ________________________ Prov./State: ___________________________
Postal/Zip Code: _____________ Ordered by: ___________________________
Phone: ____________________________ Fax: ___________________________
Email: _____________________________________________________________
ORDER INFORMATIONPurchase Order: _____________________________________________________
Order Date: __________________________________ Quote Date: ____________
FCI Representative: __________________________________________________
Payment Terms: _____________________________________________________
CREDIT CARD (check One) Visa MasterCard Exp. Date: ___________
Card Number: _______________________________________ __________
Name On Card: _________________________________________________
Signature: ______________________________________________________
SHIPPING INSTRUCTIONS
Name: _____________________________________________________________
Address: ___________________________________________________________
City: _______________________________________________________________
Province/State: ______________________________________________________
Postal/Zip Code: ________________ Phone: ______________________________
Federal ID/SS#: ______________________________________________________
CHEST HARNESS
ACCESSORIES
Self Centering Spring Locking Hand Brake (std) Safety Flag Wheel Reflectors (std)
Effective January 19, 2016 Page 3
Neoprene Chest Harness - Medium
Neoprene Chest Harness - Large
Neoprene Chest Harness - Extra Large
X Small Small Medium Large
Custom (call for price)
A. Measure width of palm
Animal Squeaky Horn (n/c)Multitool (std)Bell (std)Tool Pouch Bike Covers Cane/Crutch Holder Oxygen Tank Holder (Specify Tank Size ____________) iPad/Tablet Holder Communication Tray Simulated Sheepskin Seat Cover Child ($118.60) Adult ($132.78)
Freight (crated) ($200.00)
Residential Delivery
Tax 1
Tax 2
Other
Indoor Stationary Trainer
24. Abductor (Removable Leg Divider)
25. Padded Leg Adduction Strap