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Custom Contoured Seat Order Form - MSRP

Page OnePhone 800.676.5030

Fax 330.545.6389

Office Use Only:

Knob Release Kit (2-Point Mount)................................. #13007-15

One Inch Drop, U-Clamp Hardware Mounting Kit........... #2200-99

Velcro Hook & Loop Attachment (seat pan mount) ...... #13009-PM No Charge

Omit Mounting Hardware................................................ ($35.00)

Mounting Hardware-Options

Foam In Place Kits1/2 unit size..........................................................................#13011-FIP

1-full unit size.....................................................................#13011-FIP2

Soft Sunmate

Soft SunmateMedium Sunmate

Medium Sunmate

Qty:

Qty:

A-

B-

C-

D-

E-

F-

G-

H-

I-

J-

1" Drop Hook Kit............................................................ #2211-99

2" Drop Hook Kit............................................................ #2213-99

3"Drop Hook Kit.............................................................. #2215-99

No Charge

No Charge

No Charge

Flush-Mount U-Clamp Hardware Mounting Kit...............

Cushion Separated from wood.............................#13007-22 $128.00

Full-Width Custom Contoured Seat................#13003-SA

Seat-Mount InformationStandard

Oversized Seat Upgrade..................................... #13007-05 $114.00Actual Seat width 20-23" or > 20" deep

Between-The-Rails-Custom Contoured Seat.....#13003-SA

Mounting Location Flush Mount 1" Drop 2" Drop 3" Drop

No ChargeSeat width will be 3'' narrower than chair width

Seat Contour-OptionsNote- Standard foam contour selection will pre-determine ABD/ADD and the Anti-thrust heights inside cushion. Custom dimensions can be made in-lieu or in-junction with the standard foam contour selections. Custom dimension selections will override standard contour selections.

Mild Foam Contours (1/2 inch build-ups)

Moderate Foam Contours (1 inch build-ups)

Aggressive Foam Contours (1-1/2 inch build-ups)

Custom Contoured Seat................................#13003-SA...........$965.00

Track Mount Hardware............................... #13010-TM2

T-Nut for Attachment ................................................................ No Charge

Omit Track & T-nuts..................................................................... ($6.00)

Omit Wood ................................................................................. ($6.00)

A-

B-

Seat Tubing Size7/8" Tubing Size1" Tubing Size

QUOTE ORDER PO#

Other :

Company Name:

Phone #

Client Name:

W/C Make:

W/C Model:

W/C Width:

Seat Depth:

Non-Rehab Frame

Contact Name:

Frame Color:

HCPC E2609

No Charge#2199-99

Knob Release Kit (4-Point Mount).............................. #13010-19 Standard

must be ordered with Back 2-point kit w/seat-to-back-brackets

No Charge

$154.00

$209.00

No Charge

NEW FEATURES! Includes: 4 -Point knob release mounting hardware, premium foam and Upholstery upgrade

Standard

Bariatric Seat Upgrade..................................... #13007-06 $155.00Actual Seat width 24"

Bariatric Oversized Seat Upgrade ...................... #13007-07 $201.00Actual Seat width 25-30"

Leg-Length discrepancy (Left or Right).............. #13005-LLD.........$67.00

Pelvic Obliquity Upgrade.....................#13005-OB.................No Charge

Wedge Upgrade.................................... #13008-WS...............No Charge

(choose multiple options)

Seat Rail Cut Outs (Full width drop in style seat)....#13007-15..... No Charge

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Page Two

I-Cut Seat ( For x-brace and hardware clearance).............#13007-13.......$84.00

Anti-Thrust.............(Included in price, use for dimensions of anti-Thrust)

A-

B-

A-

B-

C-

D-

E-

A-

B-

A-

B-

Seat Options Sheet

Notched Seat Upgrade (Growth Tail).......#13007-10...............$40.00

A-

B-

C-

F-

D-

E-

C-

D-

E-

F-

G-

H-

C-

D-

E-

A-

B-

C-

D-

E-

F-

A-

B-

C-

D-

Seat Notes:

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Page Three

1/2" Medium Polyurethane Foam .......... #13040-04 $15.001" Soft Polyurethane Foam.................... #13040-03 $15.00

1/2" Soft Polyurethane Foam................. #13040-02 $7.00

1" Medium Polyurethane Foam.............. #13040-05 $23.00

1/4" Soft Polyurethane Foam................. #13040-01 $5.00

(Mid-Layer Foam)

1/2" Soft Visco Elastic Foam ........................ #13040-08 $37.00

1" Soft Visco Elastic Foam............................ #13040-10 $73.00

1/2" Super Soft Visco Elastic Foam.............. #13040-06 $37.00

1" Super Soft Visco Elastic Foam ................ #13040-07 $73.00

1/2" Soft SunMate Foam........................ #13040-11 $49.00

1" Soft SunMate Foam............................ #13040-12 $97.00

1/2" Medium SunMate Foam.................. #13040-13 $49.00

1" Medium SunMate Foam..................... #13040-14 $97.00

Poly FoamsVisco Elastic

SunMate Brand Foam

1/2" Neoprene Foam .................................... #13040-15 $27.00

Neoprene Foam

1/2" Soft SunMate Foam ................... #13050-10 $49.00

1" Soft SunMate Foam ...................... #13050-11 $97.00

1/2" Medium SunMate Foam.............. #13050-12 $49.00

1" Medium SunMate Foam................. #13050-13 $97.00

1/2" Poly-Gel (Cubed) ................................. #13050-16 $320.001/2" Poly-Gel (Flat) ...................................... #13050-15 $320.00

1/2" Poly-Gel (Cubed) > 20" width or ht....... #13050-18 $402.001/2" Poly-Gel (Flat) > 20" width or ht. ......... #13050-17 $402.00

1/2" Poly-Gel Inlay (Cubed) ........................ #13050-20 $122.00Top Middle Bottom

1/2" Poly-Gel Inlay (Flat).............................. #13050-19 $122.00

Top Middle Bottom

SunMate Brand Foam

Polymer GelOverlay-full sheet

Inlay half-sheet

1/2" Medium Polyurethane Foam........ #13050-04 $15.00

(Top-Layer Foam)

1/2" Soft Visco Elastic Foam ........................ #13050-08 $37.00

1" Soft Visco Elastic Foam .......................

1/2" Super Soft Visco Elastic Foam.............. #13050-06 $37.00

1" Super Soft Visco Elastic Foam................. #13050-07 $73.001" Soft Polyurethane Foam ................ #13050-03 $15.00

1/2" Soft Polyurethane Foam ............. #13050-02 $7.00

1" Medium Polyurethane Foam...........

1/4" Soft Polyurethane Foam.............. #13050-01 $5.00Poly Foams Visco Elastic

1/2" Neoprene Foam........................... #13050-14 $27.00

Neoprene Foam

Foam Options & Upgrades

(Base-Layer Foam)

1/2" Medium Polyurethane Foam............ #13030-07 $15.001" Soft Polyurethane Foam..................... #13030-06 $15.00

1/2" Soft Polyurethane Foam.................. #13030-05 $7.00

1" Medium Polyurethane Foam............... #13030-08 $23.00

1/2" Soft Visco Elastic Foam......................... #13030-11 $37.00

1" Soft Visco Elastic Foam............................ #13030-12 $73.00

1/2" Super Soft Visco Elastic Foam ............. #13030-09 $37.00

1" Super Soft Visco Elastic Foam.................. #13030-10 $73.00

1/2" Soft SunMate Foam......................... #13030-13 $49.00

1" Soft SunMate Foam............................ #13030-14 $97.00

1/2" Medium SunMate Foam.................. #13030-15 $49.00

1" Medium SunMate Foam..................... #13030-16 $97.00

Poly FoamsVisco Elastic

SunMate Brand Foam

1.5" Etha-Foam...................................... #13030-03 $37.00

1" Etha-Foam ........................................ #13030-02 $25.00

1/2" Etha-Foam ..................................... StandardEtha-Foam (high density)

1/2" Neoprene Foam.................................... #13030-04 $27.00

Neoprene Foam

Foam Notes:

2 3/4" Single Chamber Cushion .................. #13060-V1 $320.002 3/4" Dual Chamber Cushion..................... #13060-V2 $320.00

VARILITE Air-Foam Floatation Insert

$23.00#13050-05 Standard

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Upholstery Options

Dartex (fabric Side) Black-10Dartex Reversed (Smooth) Black-11Air-mesh Black-12 Neoprene Black-13Neoprene Velcro-Sensitive Black-14Darlex Black-15Cordura Black-16Vinyl Black-17Naugaform Black-18

Select ONE Fabric Style For Contact Surface

Select ONE Fabric Style For Non-Contact Surface

Step-ONE

Step-TWO

Incontinent Inner-Liner Cover.............#13008-IC..........$122.00

Removable / Stretchy Slip Cover.......#13011-NC..........$150.00

Dual Slip covers.................................#13011-NC2........$300.00

Slip Covers / Liner's

Dartex (fabric Side) Black-10

Dartex Reversed (Smooth) Black-11

Air-mesh Black-12

Dartex (fabric Side) Black-10

Dartex Reversed (Smooth) Black-11

Choose Contact Surface Choose Non-Contact Surface

Upholstery Notes:

Dartex (fabric Side) Black-10Dartex Reversed (Smooth) Black-11Darlex Black-15Cordura Black-16Vinyl Black-17Naugaform Black-18

Deep Violet Vinyl-20Blue Sparkle Vinyl-21Gold Sparkle Vinyl-22Burgundy Sparkle Vinyl-23Hot Pink Sparkle Vinyl-24Fuschia Sparkle Vinyl-25Silver Sparkle Vinyl-26Charcoal Sparkle Vinyl-27Green Sparkle Vinyl-28Cascade Sparkle Vinyl-29

Dove Vinyl-40Graymist Vinyl-41Blue Vinyl-42Passion Purple Vinyl-43Blueberry Vinyl-44Butterscotch Vinyl-45Red Swirl Vinyl-46

Orange Vinyl-48Hot Pink Vinyl-49Sun Yellow Vinyl-50CrocusVinyl-51Sky Blue Vinyl-52Carbon Vinyl-53Greystone Vinyl-54Fern Vinyl-55Crocus Vinyl-56

Space Blue Vinyl-47

Colored Vinyls

http://www.icrehab.com/files/Section%2012-Upholstery_Colors.pdf

To view upholstery Colors, please click link below

Slim-fit Brackets Lever Release Hip Support Brackets

5x7 (Large)

(E0956) $78.00

(E0956 / E1028) $488.00

(Pair)(Pair)

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Hip Support Options

Note: All Lateral Pads Come Standard with 1/2'' Of neoprene Foam and STD Dartex upholstery unless stated otherwise.

Foam Upgrade Options #0099 $20.00

Choose Hardware...............................

2" Offset

1" Offset

0" Offset

5" Bracket

6" Bracket

Choose Pad Style........................

(1/4" ABS) Base Support (1/2" Wood) Base Support

Choose Size........................................

4x6 (Medium)

3x5 (Small)

Choose Foams....................

1/2" Medium Polyurethane Foam 1" Soft Polyurethane Foam

1/2" Soft Polyurethane Foam

1" Medium Polyurethane Foam

1/4" Soft Polyurethane Foam

1/2" Soft Visco Elastic Foam

1" Soft Visco Elastic Foam

1/2" Super Soft Visco Elastic Foam

1" Super Soft Visco Elastic Foam

1/2" Soft SunMate Foam

1" Soft SunMate Foam

1/2" Medium SunMate Foam

1" Medium SunMate Foam

Poly Foams

Visco Elastic

SunMate Brand Foam

1/2" Neoprene Foam ..........................(standard)

Choose Upholstery...............

Match Upholstery of Seat ..........................(standard)

Included in back upholstery price

Lateral Upholstery Notes:

Other (explain below)

STD Dartex

Reversed Dartex

Add on top of standard foam...............(standard option)

Replace standard foam..................choose multiple options below

Rectangular Pads (wood only)

A-

B-A-

B-

C-

D-

Contoured Pads (wood only)

$118.00

$118.00

$118.00

$160.00 $160.00

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Removable Knee Adductor (E0956/E1028)

(One) 7/8" Frame-Mount Bracket........................#11067-E...................$329.00.

(Pair) 7/8" Frame-Mount Brackets......................#11067-2...................$658.00.

(One) 1" Frame-Mount Bracket...........................#11068-E...................$329.00.

(Pair) 1" Frame-Mount Brackets........................#11068-2...................$658.00..

Hanger-Mount Knee Adductors(Polymer-Gel pad(s) and hardware included)

Fixed Knee Adductor (E0956)

"Knee Button" Style Adductors (E0956)

(Pair) "Knee Button" Adductors Brackets.............#11066................$145.00..

Small Pad (A-3") (B-4") (C-3") (D-2.5") ..................................#11059-10.........$259.00

Medium Pad (A-4") (B-5") (C-3") (D-3.5") ................................#11059-11........$259.00

Knee Abductor "Econo-Removable" (E0957 / E1028)

(Pad and hardware included)

Large Pad (A-5") (B-6") (C-3") (D-4.5") ...................................#11059-12....... . $259.00

Custom Size Pad (specify dimensions below)....................................#11059-15.........$304.00.

Abductor Pad / Options / Upgrades

SunMate foam / dartex uph.................... (no charge)

Special foam / upholstery............... #0099................ $30.00

Small Pad (A-3") (B-4") (C-3") (D-2.5")..........................#11060-10........... $362.00Medium Pad (A-4") (B-5") (C-3") (D-3.5".........................#11060-11...........) $362.00

Flip-Down Knee Abductor (E0957 / E1028)

(Pad and hardware included)

Large Pad (A-5") (B-6") (C-3") (D-4.5")............................#11060-12.......... $362.00Custom Size Pad (specify dimensions below) ...........................#11060-15......... $410.00

A-

B-

C-

D-

A-

B-

C-

D-

Note:SunMate foam / reversed dartex uph......(no charge)

Knee Abductor Options

(One) 7/8" Frame-Mount Bracket........................#11064-E...................$301.00.

(Pair) 7/8" Frame-Mount Brackets......................#11064-2...................$602.00.

(One) 1" Frame-Mount Bracket...........................#11065-E...................$301.00.

(Pair) 1" Frame-Mount Brackets........................#11065-2...................$602.00..

Match Seat Surface / Sunmate Foam.....(standard)

Lower Extremity Options

Velcro Release (Pair) Adjustable mount

(E0951)

Large (10"-12" Circumference)......................#110451-L...................$156.00

Ankle Cuffs

Medium (8"-10"Circumference)......................#110451-M..................$156.00Small (6"-8" Circumference)..........................#110451-S...................$156.00

Side Release (Pair) Adjustable mount

Large (10"-12" Circumference)......................#110452-L...................$156.00

Medium (8"-10" Circumference).....................#110452-M..................$156.00Small (6"-8" Circumference)..........................#110452-S...................$156.00

Padded Velcro Release (Pair)

(E0951)

Adult...........................#11003...................$60.00

Toe / Ankle Straps

Youth..........................#11002...................$58.00Child...........................#11001...................$54.00

Non-Padded Velcro Release (Pair)

Xtra Large...................#11003-XL.............$60.00

Adult...........................#11006...................$31.00

Youth..........................#11005...................$31.00Child...........................#11004...................$31.00

Xtra Large...................#11006-XL.............$31.00

Heel Loops (Pair)

(E0951)

Adult...........................#11012...................$26.00

Heel Supports

Child...........................#11011...................$26.00

Heel Cups (Pair)

Adjustable...................#11012-1................$26.00

Non-padded...................#11013-X...............$126.00Padded..........................#11013...................$167.00

2-Piece Footbuckets

7" Padded..........................#11036-01X...................$430.00

6" Padded...........................#11036-00X...................$402.005" Padded...........................#11035-90X...................$402.00

(K0108)Footbuckets

10" Padded........................#11036-04X...................$450.00

9" Padded...........................#11036-03X...................$450.008" Padded..........................#11036-02X...................$430.00

1-Piece Footbuckets

16.5" Padded..........................#11037-02X...................$450.00

14.5" Padded...........................#11037-01X...................$400.0012.5" Padded...........................#11037-00X...................$400.00

Mounting Hardware

Omit Harware

1" Clamp mount brackets.................$75.007/8" Clamp mount brackets...............$75.00

Calf Panel Straps Hyper-Cel Dbl Velcro

20"-22" Frame..........................#11048-12...................$70.00

16"-19" Frame...........................#11048-11...................$70.0012"-15" Frame...........................#11048-10..................$70.00

Calf / Leg Supports

Calf Panel Straps Hyper-Cel Dbl Side Release

20"-22" Frame..........................#11048-22...................$70.00

16"-19" Frame...........................#11048-21...................$70.0012"-15" Frame...........................#11048-20..................$70.00

(K0108)

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Page Seven

2-Point Seatbelts (Padded)

Pediatric 1" Side Release, 42" Length, STD pull (BA).......#11022-A2...........$57.00Pediatric 1" Pushbutton, 42" Length, STD pull (BA)..........#11022-D2...........$58.00

Positioning Seat Belts (E0978)

Youth 1.5" Side Release, 60" Length, STD pull (BA).........#11022-B4...........$60.00Youth 1.5" Pushbutton, 60" Length, STD pull (BA)............#11022-E4...........$69.00

Adult 2" Side Release, 80" Length, STD pull (BA).............#11022-C6...........$69.00Adult 2" Pushbutton, 80" Length, STD pull (BA).................#11022-F6...........$84.00

4-Point Seatbelts (Padded)

Youth 1.5" Pushbutton, 60" Length, STD pull (BA)............#11022-E22...........$96.00Pediatric 1" Pushbutton, 42" Length, STD pull (BA)..........#11022-A20...........$77.00

Adult 2" Pushbutton, 80" Length, STD pull (BA).................#11022-F24..........$88.00