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SERIAL NO: _ ______________
PROD DATE: _______ / _____
Customer Contact Details
Customer Name: Ship to Customer Address:
Advisor: Shipping Name:
Address: Shipping Address:
Phone: Phone:
Email: Email:
Additional Information
Notes: Current Wheelchair:
Customer Weight:
Customer Height:
Customer Disability:
Other
I declare that I am chronically sick or disabled by reason of:
I would like to be contacted by RGK:
Signature: Date: Signature: Date:
VAT Excemption Declaration (UK Only): RGK Contact Authorisation:
From time to time, RGK would like to send you exclusive information, news and
offers on everything RGK, by email or post. We will not pass any of your details
to any third party.
and that I am receiving from RGK Wheelchairs Ltd, the wheelchair specified
herein and I claim relief from Value Added Tax under group 12 of schedule 8 to
Value Added Tax Act 1994.
[email protected] Page 1RGK_OCTANE-FX_2021_V1_USD
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SERIAL NO: ________________
PROD DATE: _______ / _______
Guide:
Base product Required option Optional Extra Critical Information Information Needed
FXTXZ011 OCTANE FX
XA070 Open design
Max User Weight 110kg (242lbs)
Yes, I am within the max user weight
XW010 CAD drawing for approval XW011 CAD drawing for approval in 48 hours
XY010
XY020
XY030 Extra seat length (Provides additional leg support & hand grip)
XY050
XY060
XY070
(Max 625mm)(Min XY020 + XY030 + 140mm)
XY072
Optimise measurements
XA020 Ergonomic seat
Specify length(Standard = 120mm)
PRODUCT STYLE
$5,231.00
$135.00
CAD APPROVAL
$203.00
KEY MEASUREMENTS
mm(Max - 460mm)
$66.00
Front frame height
Seat length
mm(Max - 460mm)(Min - 250mm)
mm
mm
Seat width (Inside of sideguards)
mm(Max - 550mm)(Min - 360mm)
Frame length
mm
(Min - 250mm)
mm(Max - 550mm)(Min - 480mm)
Rear frame height
Castor position
mm
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SERIAL NO: ________________
PROD DATE: _______ / _______
XY080
Specify width
XY100 Round design XY105 Square design
XB200 XB200
XY115 Front footrest height
XY120 Rear footrest height
(Std = 20mm lower than front height)
XY125 Footrest length
(Std = 100mm)
(160mm and over requires heavy duty upgrade XB150)
FXTXB080 Tubular footrest welded w/ Aluminium plate FXTXB120 Clamp-on aluminium plate footrest
(Supplied with spacer for +20mm adjustment) (Angle/height adjustable)
FXTXB110 Tubular footrest welded w/ Carbon Fibre plate
(Supplied with spacer for +20mm adjustment)
XB165 Rubber grip tape (3M safety walk)
Footrest Options
$31.00
With
XB200
165mm
mm
High level footrest (Only with XB010, XB080 &
XB150)
Footrest Individual Measurements
High level footrest (Only with XB010, XB080
& XB150)$117.00 $117.00
4" 195mm4"
Castor
Size
Max
Height
With
XB200
175mm
3" 135mm
145mm125mm
185mm
Max
HeightCastor
Size
FRONT FRAME AND FOOTRESTFront Frame Options
mm
Seat taper design
Footrest Design (Choose One)
Optimise measurements
(XY010 Seat Width -100mm)
3" 115mm
$110.00
155mm
Footrest Style and Cover
mm
205mm5" 135mm 185mm
mm
5"
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SERIAL NO: ________________
PROD DATE: _______ / _______
XC150 Aluminium centre 3"x1.4"
(Silver hub and black urethane tyre)
XC060 Soft roll 4"x1.3"
(Black)
XC110 Aluminium centre 4"x1"
(Silver hub and black urethane tyre)
XC130 Aluminium centre 4"x1.4"
(choose colour below)
Silver hub & red tyre
XC070 Soft roll 5"x1.3" XC120 Aluminium centre 5"x1"
(Black) (Silver hub and black urethane tyre)
XC100 Pneumatic Aluminium centre 5"x1" XC140 Aluminium centre 5"x1.4"
(Grey) (Silver hub and black urethane tyre)
XC080 Soft roll 6"x1.3" XC145
(Silver hub and black urethane tyre)
XC190 XC210
Note: Colour follows accent Black Silver
XY330
XD020 XD050 Push to lock
XD030 XD046 Out Front push to lock
XD035
XD045 XD010 Omit wheel locks
Castor Pin Width
Underseat Scissor
CASTOR WHEELS, FORKS & WHEEL LOCKSCastor Wheels
$105.00
$105.00
Black hub & blue tyre
Red hub & black tyre
$105.00
$105.00
125mm (5")
Green hub & black tyreBlue hub & black tyreBlack hub & red tyre
100mm (4")
$105.00
$143.00
Castor Forks
Low ride castor fork
(Std when no option selected) $384.00
Froglegs suspension castor fork
$83.00 $143.00
Compact scissor with lightweight fixing
(Only with fixed centre of gravity)
Out Front Compact scissor
$98.00
Compact scissor
Wheel Lock Options (Choose one)
(XY010 plus 70mm)
Castor pin width
75mm (3")
Aluminium centre 6"x1.4"
150mm (6")
$105.00$118.00
Silver hub & blue tyre
Gold hub & black tyreBlack hub & black tyre
Purple hub & black tyreSilver hub & black tyre
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SERIAL NO: ________________
PROD DATE: _______ / _______
XE080 Lift out aluminium XE090 Lift out aluminium with fender
FXTXE130 Fold flat aluminium FXTXE140 Fold flat aluminium with fender
XE100 Lift out carbon fibre XE110 Lift out carbon fibre with fender
FXTXE150 Fold flat carbon fibre FXTXE160 Fold flat carbon fibre with fender
XE120 Lift out ABS plastic
FXTXE170 Fold flat ABS plastic
XF010 Lift out armrest with plastic sideguard
(Indicate fixed height)
XF020 Lift out armrest with aluminium sideguard Centre of tyre
(Indicate fixed height) (Standard if no option selected)
Height (Top of seatrail to top of armrest)
Outside of tyre
25mm above tyre
(Follow tyre)
Individual above tyre
(Follow tyre)
$337.00 $365.00
SIDEGUARDS AND ARMRESTSSideguard Sideguard with Fender
Aluminium Options Aluminium Options
Carbon Fibre OptionsCarbon Fibre Options
$531.00
$292.00 $321.00
mm
$576.00
$456.00
$472.00
Armrest Options
Sideguard MeasurementsABS Plastic Options
mm
Individual above tyre
(Min = 10mm)
10mm above tyre
(Standard)
Fender height
Sideguard length
$219.00
$292.00
Sideguard height
$376.00
$376.00
Level with tyre
(Follow tyre)
mm
mm
Fender position
Optimised measurements
Individual measurements
mm
Sideguard Measurements
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SERIAL NO: ________________
PROD DATE: _______ / _______
XY230 Fixed height backrest XY245 Adjustable height backrest
(Maximum 400mm) (Maximum height 400mm)
Specify height
FXTXG060 Folding backrest with Q Lock
(Black)
XY360 XG100
-5 -3 0
Individual
XG110 Inward taper XG120 Outward flare
XG070 Screw in push handles
(N/A with XY245)
XG080 Flip down push handles
(N/A with XY245)
XG085 Flip down push handles height adjustable
(N/A with XY245)
XG097 Integrated push handle
(quickie design)
mm
mm
Backrest angle
Deg
$198.00
Specify width or per side
mm
(inside of backrest posts)
Vertical height+3
(Max -7/+7 Deg)
(inside of backrest posts)
$218.00
Specify width or per side
mm
Specify height
$129.00
$66.00 $66.00
Push handle Options
Ergonomic backrest
$66.00
Rearward position
mm
$218.00
mm
+5
Backrest Design
Backrest Height
$110.00
(+/-25mm)
BACKREST
Ergonomic Options
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SERIAL NO: ________________
PROD DATE: _______ / _______
XH110 Square back adjustable centre of gravity FXTXH090 V-style fixed centre of gravity
(25-150mm)
(Max seat width 500mm)
Specify measurement Specify measurement
XH120 Round back adjustable centre of gravity
(60-150mm)
Specify measurement
XY390 XY390
Custom0 1 2 3 5 0 1 2 3 5
FXTXK227 Standard Axle pin XK220 Titanium 130mm quick release axle pins (pair)
(120 or 130mm)
FXTXK226 100mm Titanium Axle pin XK240 Quad release axle nuts (pair)
(Fixed Axle only)
XJ010 XJ100
XJ020
mm
mm
CAMBER BARAdjustable Centre of Gravity Fixed Centre of Gravity
mm
$275.00 (25-125mm)
Specify Camber Angle Specify Camber Angle
$150.00
Camber angle Camber angle
Camber Bar Options
$94.00
$129.00
(N/A with XK010, XK070 or FXTXK226)
(N/A with FXTXK226)
Anti-Tip Options
$118.00
$118.00
Single sport anti tip
$365.00 (centre mounted)
Swingaway anti tip LEFT side
(Only with square back frame. Not with XH040)
Swingaway anti tip RIGHT side
(Only with square back frame. Not with XH040)
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SERIAL NO: ________________
PROD DATE: _______ / _______
XY420 24" Wheels XY430 25" Wheels
XY460
Individual
XK010 Fusion 16 spoke XK320 Spinergy XLX 12 spoke, cross/radial spoked
(Silver Hub, black spokes)
XK050 Spinergy LX 12 spoke XK060 Spinergy SPOX 18 spoke
XK150 Spinergy CLX 18 carbon blade spoke XK070 Spinergy BLXL 18 blade spoke
(N/A in silver hub) (N/A in silver hub)
Spinergy Colour Options:
XK180 Individual spoke design(Specify colour)
Inside:
Outside:
Spinergy Anodise Options
XK190 XK200 XK201 XK204 Individual hub/rims(std option) (n/a with BLXL/CLX) (LX, XLX & BLXL only) Select colour:
XK202 XK203 XK204
(LX, XLX & BLXL only) (LX, XLX & BLXL only) (LX, XLX & BLXL only)
XK040 Supply without Wheels Wheel Type: Tyre Type:
XY480 Narrow set handrim XY485 Wide set handrim
XL090 Remove excess mounting tabs
(recommended for small wheel gaps)
XL010 Aluminium hard anodised 6 tab XL040 Titanium 6 tab
(Standard if no option selected)
XL160 Elipse 6 tab XL050 Stainless steel 6 tab
(replacement for Surge)
XL020 Tetra grip 6 tab XL140 Ergo gripp 6 tab wide
XL100 Para grip 6 tab
XM010 Grey Blue Red
XM130
XM020 XM060
XM040 XM050
(Black)
XY500 XY490
XK310 XK300
$657.00
$470.00
$657.00
REAR WHEELSRear Wheel Size
mm
Rear Wheel Gap
Rear wheel gap
15 20 25
Rear Wheel Options
$624.00
$1,241.00
Schraeder inner tube valve Presta inner tube valve
Shox solid airless
Handrim Position / Options
Handrim Styles
$84.00
$281.00 $110.00
$236.00 $245.00
Kenda K885 mountain bike tyre (24",25"
only)$93.00 $22.00
Inner Tube Valve Options
$236.00
Kenda
(Standard if no option selected)
Wheel Accessories
Offroad wheel set 24" rim with handrim, MTB tyre and
axle pins (Replaces 25" wheel with XM010)$537.00
Offroad wheel set 22" rim with handrim, MTB tyre and
axle pins (Replaces 24" wheel with XM010)$537.00
$203.00
Tyre Options
Kenda black
$15.00
Schwalbe Marathon Plus Schwalbe One (24",25" only)
$57.00 $79.00
$76.00 $154.00
Black spokes White spokes Yellow spokes
Red spokes Blue spokes Pink spokes
$146.00
$200.00
Supply Without Wheels
-$161.00
Purple hub/rims Blue hub/rims Gold hub/rims
$154.00 $154.00 $203.00
Purple spokes Orange spokes Green spokes
Black hub Silver hub Red hub/rims
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SERIAL NO: ________________
PROD DATE: _______ / _______
XN010 Powder coated frame XN150 Powder coated components (Frame colour if not specified)
Frame Comp. Frame Comp. Frame Comp.
XN200 Individual paint colour (State Colour/RAL code)
Frame Comp
FXTXN030 Beadblast frame XN160 Beadblast components
(All parts black unless XN160 chosen)
FXTXN050 Polished frame XN170 Polished components
(All parts black unless XN170 chosen)
Note: Accent colour includes forks only
Black accent Silver accent XN250 Individual Accent Colour
Red accent Blue accent
Purple accent
XP040 Seat sling strap adjustable XR050 Carbon fibre seat plate
FXTXP045 Sub4 Seat sling strap adjustable
XP050 Airtech backrest strap adjustable XP060 Backrest upgrade to full leather
(Black)
FXTXP035 Airtech Sub4 backrest strap ajustable XP070 Backrest upgrade to leather corners
(Black)
Silver Black Blue
Red Light blue Purple
White (Std) Black Blue
Red Light blue Purple
XP110 XP170 Individual backrest embroidery
(Provide .jpeg file and positioning)
Chrome Mirror 300
White gloss 100 White matt 101 Sparkle silver 170
Cream gloss 135 Light grey matt 133 Metallic grey matt 130
Metallic black matt 104
Black gloss 103 Black matt 105
Grey gloss 132 Grey matt 131
Red gloss 108 Navy blue matt 152
Royal blue gloss 154
UPHOLSTERYSeat Upholstery
Yellow gloss 120
White sandpaper 200
Green gloss 107
Black sandpaper 201
Grey sandpaper 202
Dark blue gloss 151
Forest green gloss 143
$281.00
$37.00
$143.00
$509.00 $135.00
Accent Colour (Choose One)
Orange gloss 180
Purple gloss 157
$200.00 $80.00
Blue gloss 174
$143.00
Duckegg blue gloss 141
Pink gloss 188
Backrest Accessories
Backrest with zip pocket
Backrest Upholstery Logo Colour
Backrest Upholstery
Individual:
Individual:
Backrest Upholstery Stitching Colour
$288.00
$77.00
$113.00
$100.00
(N/A with Sub4 backrest)$74.00
FINISH OPTIONSFrame & Component Finish
Gloss Matt Special
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SERIAL NO: ________________
PROD DATE: _______ / _______
XP080 Cushion foam
(select density and size below)
XP081 Nylon cushion cover
(Black)
XP090 Air Lite cushion cover
(Black)
XP100 Leather cushion cover
(Black)
Jay Order form attached Notes:
(Price dependant on size / option)
Jay Order form attached
(Price dependant on size / option)
JAY Whitmyer Headrest Jay Order form attached
(Price dependant on size / option)
XR080 Frontwheel assembly
(Only with tubular style footrest))
XP120 Frame protectors Neoprene zip fasten
(Black)
XP420 Frame protectors Nylon velcro fasten
(Black)
XR010 Seat pouch velcro attach (Black)
XR200
XR100 FX carry bag
XR090 Tool kit
XS060 Calf strap
$176.00
Jay Products
JAY Cushion
JAY Backrest
50mm 75mm
Cushion cover upgrades
100mm
$54.00
CUSHION
$69.00
Soft (CMS040) Medium (CMS050)
Cushion foam options
Hard (9lb recon)
ACCESSORIES
$53.00
$279.00
$606.00
Rucksack with RGK logo (Black)
$60.00
$40.00
$31.00
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ENGLISH
SERIAL NO: ________________
PROD DATE: _______ / _______
NOTES
[email protected] Page 11RGK_OCTANE-FX_2021_V1_USD
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