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Finished Dimensions Standard cut is wood with foam rolled over edge
C - Lateral Width (Chest Width)
B - Lateral Height
D - Hip Width
I - Back Width
BLOCK Font Thread Color Script OR
Upholstery, Monograms, and Designs:
Total system covered in one upholstery?
Contact Surface
Non-contact Surface
Monogram Name
Design
NO YES
Seating Specifications:
E - Set Up Seat Depth (Back to Knee –1”)
G - “E” + 3” for Growth
H - Seat Width
A - Back Height (Top Of Shoulder)
Freedom Designs, Inc Easy Form
Quote Order
E-mail Address
Fax Number
Install Program
Freedom Seating on Freedom Frame
Freedom Seating on Other Manufacturer’s Manual Frame
P.O. for Frame
*Let other manufacturer know that frame needs to be shipped to Freedom Wheelchair Specifications:
Width:
Depth:
Model:
Confirmation
2241 N. Madera Rd, Simi Valley, CA 93065 Phone: 800 331-8551 Fax: 888 582-1509 www.freedomdesigns.com
SOEO 22015 Page 1
Dealer/Acct. #:
Buyer:
Ship to Address:
Phone Number:
Marked For:
Purchase Order #
Date:
Seat Foam Chart
3# Foam $ 45per 1” Firm Sunmate $ 82per 1” Pudgee $209per 1”
4# Foam
$45per 1”
X-Soft T-Foam $ 89per 1” Waffle $269per .5”
5# Foam
$ 47per 1” Soft T-Foam $ 89per 1”
Waffle (over 18x16) $540per .5”
Soft Sunmate
$ 82per 1”
Medium T-Foam $ 89per 1”
Free Float $338per .5”
Med. Sunmate
$ 82per 1”
Firm T-Foam $ 89per 1”
Free Float (over18x16) $674per .5”
Freedom Designs, Inc Easy Form - Seat
M/F: _____________________ Step 1. Choose Hardware for Planar / Flat Seat Note: Price includes 1/2” wood, 1-1/2” 4# foam and choice of upholstery.
EE1
EE1-No Hardware
EZ Lite 1
EZ Lite 1-EXT
101-1000
101-1000A
101-7000
101-7500
101-10000
101-10000-EXT
Two Knobs/Hinge (transport approved)
Two Knobs/Hinge - No Hardware
Two EZ Lite/Hinge
Two EZ Lite/Hinge (transport approved)
Seat Insert
Seat Inserts w/T-Nuts
J/L Quick Release (transport approved)
Four Knobs (transport approved)
Four EZ Lite
Four EZ Lite Extended (transport approved)
$646
$237
$471
$471
$172
$225
$602
$698
$471
$471
A
B
C
D
B
C
A
D
A _________ B _________ C _________ D _________
A _________ B _________ C _________ D _________
MOD-1CR Asymmetrical - Long Right Add $ 88 MOD-1CL Asymmetrical-Long Left Add $ 88
C Leg trough depth is 1”
Height of anti-thrust is 1”
C = Half of set up seat depth (see page1)
Height of anti-thrust shelf is 1”
C = 3rd of set up seat up depth (see page1)
Step 2. Choose Modifications to Planar / Flat Seat
MOD-1K Anti-Thrust Seat Add $210 MOD-1Y Contour Seat Add $362
C
MOD - 1G
MOD - 1I
MOD - 1L
MOD - 1O
MOD - 1P
MOD - 1DD
MOD - 1EE
MOD - 1FF
MOD - 1GG
MOD - 1ROHO Seat
Cushion Separate From Wood
Incontinent Liner
Grid Seat Modification
Notch For Back Posts
Hook & Loop Strips
Modular Contour Seat
Foam Full Width / Wood Between
Removable Incontinent Slip Cover
Track Mount Hardware - Long Dual Tracks
Freedom Seat ROHO Insert (see pg. 8 to specify order)
Add $105
Add $ 30
Add $333
n/c
Add $ 47/pr
Add $432
Add $164
Add $204
Add $ 53/pr
Add $765
1.5” Std 4# Foam Only OR Custom/Omit Standard (see chart below)
Base layer to be: Middle layer to be: Top layer to be:
Step 3. Choose Foam
2241 N. Madera Rd, Simi Valley, CA 93065 Phone: 800 331-8551 Fax: 888 582-1509 www.freedomdesigns.com
SOEO 22015 Page 2
Soft Medium
Soft Medium
M/F: _____________________
Freedom Designs, Inc Easy Form - Back
EE2
EE2-No Hardware
Easy Clamp2
Fast Clamp2
Rotate 2
102-7500
102-Easy Clamp
102-32000
Two Knobs/Hinge (transport approved)
Two Knobs/Hinge - No Hardware
Two Easy Clamps/Hinge (transport approved)
Two Fast Clamps (transport approved)
Two Rotate Clamps/Hinge (transport approved)
Four Knobs (transport approved)
Four Easy Clamps (transport approved)
Four Rotate Clamps (transport approved)
$646
$238
$549
$443
$462
$762
$639
$462
Step 2. Choose Modifications to Planar / Flat Back
Step 1. Choose Hardware for Planar / Flat Back Note: Price includes 1/2” wood, 1” 4# foam and choice of upholstery.
D
B
E
C
A
A________ B________ C________ D________ E________
MOD-2I Curved Wood Add $134
MOD-2IA Curved Foam Add $115
MOD-2H I-Mod Add $128
MOD-2J T-Mod Add $128
B________ C________ D________ E________
Back Foam Chart
3# Foam $ 45per 1” Firm Sunmate $105per 1” Pudgee $226per 1”
4# Foam $ 45per 1”
X-Soft T-Foam $113per 1”
Waffle $269per .5”
5# Foam
$ 62per 1”
Soft T-Foam $113per 1”
Waffle (over 18x16) $540per .5”
Soft Sunmate
$105per 1”
Medium T-Foam $113per 1”
Free Float $338per .5”
Med. Sunmate
$105per 1”
Firm T-Foam $113per 1”
Free Float (over18x16) $674per .5”
Step 3. Choose Foam
1” Std 4# Foam Only OR Custom/Omit Standard (see chart below)
Base layer to be: Middle layer to be: Top layer to be:
MOD-2L Biangular Add $303 MOD-2DD Adjust. Lumbar Add $299
MOD - 2K
MOD - 2ROHO Back
MOD - 2S
MOD - 2S1
MOD - 2GG
MOD - 2JJ
Grid Back
Freedom Back ROHO Insert (see pg.9 to specify order)
Foam-In-Place
Foam-In-Place (chemicals only)
Ergo Adjustable
Track Mount Hardware - Long Dual Tracks
Add $333
Add $765
Add $259
Add $242
Add $422
Add $ 58/pr
Split at from bottom Start at from bottom
2241 N. Madera Rd, Simi Valley, CA 93065 Phone: 800 331-8551 Fax: 888 582-1509 www.freedomdesigns.com
SOEO 22015 Page 3
EE3B-2 Flip Down Abductor $444 Wedge Or Oval
MOD-3E Abductor Pad Only $170
MOD-3F Extension Bracket/Abductor $ 28
EE3M Anti-Thrust Pelvic Harness $247 S M L XL or Hip Width____
Hip Guides
$237/pair
$474/pair
$ 90/pair
$ 42/ea
Fixed - Flush/Offset
Quick Release Hip Guide
Contour for Anti-Thrust
Extension Bracket/Add
EE4A/B
EE4C
MOD-4A
MOD-4D
A B
A = 4” high or _____”
B = Set up seat depth or _____”
M/F: ________________________
A________ B________ C________ D________
Standard Sizes
Small 3L x 3H x 3-2 Taper
Medium 4L x 3H x 3-2 Taper
Large 5L x 4H x 4-2 Taper
X-Large 6L x 5H x 5-3 Taper
Freedom Designs, Inc Easy Form - Accessories
Medial Thigh - Abductor/Pommel
Belts
$ 68
$ 90
$ 90
$110
XS
XS
XS
XS
SB-3331
SB-3332
SB-3334
SB-3362
Squeeze Release, 2 pt., Center Pull
Metal Push Button, 2 pt., Center Pull
EZ-Release, 2 pt., Center Pull
EZ-Release, 4 pt., Center Pull
S
S
S
S
M
M
M
M
L
L
L
L
XL
XL
XL
XL
7700
7702
7708
7709
7711
7733
77Platemate
$144
$281
$393
$402
$230
$ 63
$ 43
Vertical and Horizontal Adjustment - Fixed Removable
Flip Down - Not Removable
Rock and Roll Removable
Rock and Roll Flip Down - Not Removable
NEW Adjust-Eze Multi-Position Removable
Adaptaplate - Universal Plate - Freedom Designs and Other Manufactures
Universal Plate for all Headrests - Whitmyer, Otto Bock, Stealth
Headrest Hardware
W_______________ x H_______________
Headrest Pads
Trunk Supports A _______
B _______
4L x 3H
5L x 4H
6L x 5H
B
A
Tracks
3” Single
5” Single
7” Single
9” Single
11” Single
9” Double
11” Double
EE5A/B
EE5E
EE5I
EE5J
EE5K
EE5P
EE5Q
EE5W
MOD-5F
Fixed - Flush/Offset
Lift Swing Away
Tracks
Fixed Swing Away Summer Winter
Lever Swing Away Summer Winter
Lever Swing Away
Swing Away Summer Winter
NEW Push Button S/A
Protective Covering Over Hardware
$237/pair
$474/pair
$ 52/pair
$402/pair
$633/pair $532/pair
$669/pair $474/pair
$ 54/pair
Trunk Supports
Std. (1” thick) OR Thin (.5” thick)
Flat OR Curved
Flush 1” 2”
Flush 1” 2”
Mounted at: Hip or Knee
$124
$314
$188
$149
$188
Small 10W x 4H
Small 8.5W x 3.5H
Small 4W x 4H
Small 8W x 4.5H
7755
7753
7756
7757
7760
Extension Pad
3-Piece Hinged
Chubbie
Low Profile
Skinny
Medium 12W x 5H
Medium 9W x 4H
Medium 5W x 4H
Medium 10W x 4.5H
Large 13.5W x 4.5H
Large 13W x 4H
Large 5W x 5H
Large 12W x 4.5H
2241 N. Madera Rd, Simi Valley, CA 93065 Phone: 800 331-8551 Fax: 888 582-1509 www.freedomdesigns.com
SOEO 22015 Page 4
C A
B
D
Shoe Holders - Velcro
Shoe Holders - Buckle
Shoe Holders - Combo
Shoe Holder Sizing =
Foot Plate Pads - Pair W______ x D______
Shoe Holders
M/F:_________________________
Freedom Designs, Inc Easy Form - Trays and Foot Boxes
Tray Sizes
Size Description
X-Small 10” - 11” wide chair, Tray dimensions—21”wide x 18” deep, body cut out— 10” w x 7” deep
Small 12” - 13” wide chair, Tray dimensions—21”wide x 18” deep, body cut out— 12” w x 7” deep
Medium 14” - 15” wide chair, Tray dimensions—24”wide x 22” deep, body cut out— 14” w x 9” deep
Large 16” - 17” wide chair, Tray dimensions—26”wide x 24” deep, body cut out— 16” w x10” deep
X-large 18” - 19” wide chair, Tray dimensions—28”wide x 14” deep, body cut out— 18” w x10” deep
W—Fits between hangers
D ___________________
H ___________________
Hanger Mount
Footplate/Footboard Mount
Tray
What is the width of the frame _____________________?
Ankle Circumference =
Ankle Supports
$111
$169
X-Small
X-Small
EE9B-D
EE9F-D
High Top, Buckle, Dynamic
3 Point High Tops
Medium
Medium
Large
Large
Small
Small
08-10000 Leg Cradles $603 08-11000 Foot Box $515
Foot Boxes
EE9
EE9C
EE9G
MOD-9G
A _________ B _________ C _________ D _________
(5 1/2 - 8 1/2”) (7 1/2 - 10 1/2”) (9 1/2 - 12 1/2”) (11 1/2 - 14 1/2”)
2241 N. Madera Rd, Simi Valley, CA 93065 Phone: 800 331-8551 Fax: 888 582-1509 www.freedomdesigns.com
SOEO 22015 Page 5
$197
$273
$220
$159
$170
$183
$106
08-1000
08-2000
08-6000
08-8000
08-12000
08-13000
08-16000
Lexan Tray w/Velcro
Lexan Tray w/Channel Brackets & Ribs
Lexan Tray w/Adjustable Hardware & Ribs
Lexan Tray No Hardware
EZ-Lite Tray
EZ-Lite Tray with Ribs
1/4” Lexan Tray w/Hook & Loop
$166
$166
$166
$161
M
M
M
ML
ML
ML
L
L L
XL
XL
XL
SM
SM
SM
S
S S
(5”) (5.75’) (6.5”) (7.25”) (8”) (10”)
Length of Pad
Chest Support
XXS XS S M L XL
EE6R 12" 15.5" 17.25" 18.75" 20.25" 21.5"
EE6S 12.5" 14.25" 15.5" 17" 18.25" 20"
EE6U N/A 10" 11" 11.75" 12.5" 14.5"
EE6V N/A 10" 14" 16.25" 20" 22"
EE6X N/A N/A 9.25" 11.25" 13.5" N/A
EE6X $165
EE6S $164
EE6U $164
EE6V $164
EE6R $164
XXSmall
XSmall
Small
Medium
Large
XLarge
Size
M/F: _____________________
MOD-6A-1 $53/pr. Strap Riser
Freedom Designs, Inc Easy Form - Anterior Chest Supports
2241 N. Madera Rd, Simi Valley, CA 93065 Phone: 800 331-8551 Fax: 888 582-1509 www.freedomdesigns.com
SOEO 22015 Page 6
Quote Order
Freedom Designs, Incorporated 2241 N Madera Road, Simi Valley, CA 93065
phone: 800-331-8551 fax: 888-582-1509
www.freedomdesigns.com
Freedom Select Anterior Trunk Support
Order Part Number Freedom Select Support Dimensions Price
A B C D E F G
SFDI-6SNZ-S Select Standard Small 7.5 4.5 3.25 6 11 5.25 13.75 $ 13о
SFDI-6SNZ-M Select Standard Medium 9.5 6.5 4 6.5 14.75 7.25 17 $ 13о
SFDI-6SNZ-L Select Standard Large 10.5 7.5 4.5 6.75 18 9 19.75 $ 14о
SFDI-6SNZ-XL Select Standard 10.5 7.5 4.5 7.75 21.75 10 22 $ 14о
SFDI-6NNZ-M Select Narrow Medium 9.5 6.5 4 3 14.75 7.25 17 $ 13о
SFDI-6NNZ-L Select Narrow Large 10.5 7.5 4.5 3.5 18 8 19.75 $ 13у
SFDI-6NNZ-XL Select Narrow Extra Large 10.5 7.5 4.5 4.25 21.75 10 22 $ 14о
SFDI-6SZ-S Select Standard Zipper Small 7.5 4.5 3.25 6 11 5.25 13.75 $ 13у
SFDI-6SZ-M Select Standard Zipper Medium 9.5 6.5 4 6.5 14.75 7.25 17 $ 13у
SFDI-6SZ-L Select Standard Zipper Large 10.5 7.5 4.5 6.75 18 9 19.75 $ 14о
SFDI-6SZ-XL Select Standard Zipper Extra Large 10.5 7.5 4.5 7.75 21.75 10 22 $ 14у
SFDI-6NZ-M Select Narrow Zipper Medium 9.5 6.5 4 3 14.75 7.25 17 $ 13у
SFDI-6NZ-L Select Narrow Zipper Large 10.5 7.5 4.5 3.5 18 8 19.75 $ 14о
SFDI-6NZ-XL Select Narrow Zipper Extra Large 10.5 7.5 4.5 4.25 21.75 10 22 $ 14у
FSATS 112013
Buyer:____________________________ Co./Account:_______________________ Location:__________________________ Contact #:_________________________ P.O.:_____________________________ Marked For:_______________________ Fax:______________________________ Email:____________________________
Select Standard Select Narrow Select Standard Zipper Select Narrow Zipper
Freedom Select Anterior Trunk Supports
Page 7
Cell Size
INCHES 3 4.75 6.5 8 9.75 11.5 13.25 15 16.5 18.25 20 21.75CELLS 1 2 3 4 5 6 7 8 9 10 11 12
A B C D E F G H I J K L
Deleted Cells Base Intact
3 1
4.75 2
Cut Out Cells & Base
6.5 3
8 4
9.75 5Valve Hose
Location Corner & Cell
Height
RO 11.5 6WS 13.25 7
15 8
16.5 9
18.25 10
20 11Select Seat
Choice
Standard
AsymmetricalLeft
Asymmetrical Right
Other
21.75 12
FRONT OF INSERTCOLUMNS
1. Start diagram at cell 1A which represents front left of seat from client’s seated position.2. Specify “Cell Height” (1”, 2”. 3” or 4”) by placing a number in each cell box.3. Specify request to “Delete Cells with Base Intact” by typing an “X” in those cell boxes.4. Specify request to “Cut Out Cells & Base” by typing a “C” in those cell boxes.5. Specify “Valve Hose Location Corner & Cell Height” by typing “V1”, V2”, V3” or “V4” in that corner box. Note: For multiple valve or custom valve locations and custom air chamber divisions call
PLEASE ALLOW 3-4 WEEKS FOR DELIVERYPLEASE ALLOW 3-4 WEEKS FOR DELIVERY
1”
2”
3”
X
C
V1
V2
V3
PO#___________________________ M/F:______________________________
4”
V4
2241 N. Madera Rd., Simi Valley, CA 93065 Phone: 800 331-8551 Fax: 888 582-1509 www.freedomdesigns.comSOEO 22015 Page 8
Freedom Designs, IncEasy Form - ROHO Seat Insert
MOD-1ROHO SEAT MOD-1ROHO SEAT Freedom Seat ROHO InsertFreedom Seat ROHO Insert $7.00 $765.00 Note: Retail pricing includes any combination of specif cation option. Note: Retail pricing includes any combination of specif cation option.
INCHES ARE FROM BASE EDGE TO EDGE OF INSERT
TOP OF INSERTCOLUMNS
PLEASE ALLOW 3-4 WEEKS FOR DELIVERYPLEASE ALLOW 3-4 WEEKS FOR DELIVERY
1”
2”
X
C
V1
V2
V3
PO#___________________________ M/F:______________________________
3”
2241 N. Madera Rd., Simi Valley, CA 93065 Phone: 800 331-8551 Fax: 888 582-1509 www.freedomdesigns.comSOEO 22015 Page 9
Freedom Designs, IncEasy Form - ROHO Back Insert
INCHES ARE FROM BASE EDGE TO EDGE OF INSERT1. Start diagram at cell 1A which represents top right of back from client’s seated position.2. Specify “Cell Height” (1”, 2”. or 3”) by placing a number in each cell box.3. Specify request to “Deleted Cells with Base Intact” by typing an “X” in those cell boxes.4. Specify request to “Cut Out Cells & Base” by typing a “C” in those cell boxes.5. Specify “Valve Hose Location Corner & Cell Height” by typing “V1”, V2”, or “V3” in that corner box. Note: For multiple valve or custom valve locations and custom air chamber divisions call Freedom Designs Customer Service for assistance at 800-331-8551
Cell Size
INCHES 3 4.75 6.5 8 9.75 11.5 13.25 15 16.5 18.25 20 21.75CELLS 1 2 3 4 5 6 7 8 9 10 11 12
A B C D E F G H I J K L
Deleted Cells Base Intact
3 1
4.75 2
Cut Out Cells & Base
6.5 3
8 4
9.75 5
Valve Hose Location
Corner & Cell Height
RO 11.5 6WS 13.25 7
15 8
16.5 9
18.25 10
20 11
Select Back Choice
Standard
“I” Back
“T” Back
21.75 12
MOD-2ROHO BACK MOD-2ROHO BACK Freedom Back ROHO InsertFreedom Back ROHO Insert $7.00 $765.00 Note: Retail pricing includes any combination of specif cation option. Note: Retail pricing includes any combination of specif cation option.
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