PRIDE TB3 ACTA-BACK® DEEP

SEATING SYSTEM

HCPCS CODING: E2615/E2616POSITIONING BACK, POSTERIOR LATERAL

ORDER FORM 1 of 3Patient Reference:ACTA-BACK DEEP TB3 ORDER FORM

ORDER FORM

STRETCH AIR

STRETCH AIR

SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION. PROVIDES NO INCONTINENCE PROTECTION.

COMFORT TEK

COMFORT TEK

SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE.

OR

FRAME WIDTH

BK-M3D-22FP3-16

BK-M3D-22FP3-18

BK-M3D-22FP3-20

BK-M3D-22FP3-22

BK-M3D-22FP3-24

BK-M3D-20FP3-14

BK-M3D-20FP3-16

BK-M3D-20FP3-18

BK-M3D-20FP3-20

BK-M3D-20FP3-22

BK-M3D-20FP3-24

BK-M3D-18FP3-14

BK-M3D-18FP3-16

BK-M3D-18FP3-18

BK-M3D-18FP3-20

BK-M3D-18FP3-22

BK-M3D-18FP3-24

BK-M3D-16FP3-14

BK-M3D-16FP3-16

BK-M3D-16FP3-18

BK-M3D-16FP3-20

BK-M3D-16FP3-22

BK-M3D-14FP3-12

BK-M3D-14FP3-14

BK-M3D-14FP3-16

BK-M3D-14FP3-18

BK-M3D-14FP3-20

BK-M3D-12FP3-12

BK-M3D-12FP3-14

BK-M3D-12FP3-16

BK-M3D-12FP3-18

16”

18”

20”

16” 18” 20” 22”

$60100 $67700

12” 14”

14”

12”

24”

22”

$67800 $75400

16” 18” 20”12” 14” 22” 24”

FRAME WIDTH

BK-M3D-22UP3-16

BK-M3D-22UP3-18

BK-M3D-22UP3-20

BK-M3D-22UP3-22

BK-M3D-22UP3-24

BK-M3D-20UP3-14

BK-M3D-20UP3-16

BK-M3D-20UP3-18

BK-M3D-20UP3-20

BK-M3D-20UP3-22

BK-M3D-20UP3-24

BK-M3D-18UP3-14

BK-M3D-18UP3-16

BK-M3D-18UP3-18

BK-M3D-18UP3-20

BK-M3D-18UP3-22

BK-M3D-18UP3-24

BK-M3D-16UP3-14

BK-M3D-16UP3-16

BK-M3D-16UP3-18

BK-M3D-16UP3-20

BK-M3D-16UP3-22

BK-M3D-14UP3-12

BK-M3D-14UP3-14

BK-M3D-14UP3-16

BK-M3D-14UP3-18

BK-M3D-14UP3-20

BK-M3D-12UP3-12

BK-M3D-12UP3-14

BK-M3D-12UP3-16

BK-M3D-12UP3-18

16”

18”

20”

16” 18” 20” 22”

$60100 $67700

12” 14”

14”

12”

24”

22”

$67800 $75400

16” 18” 20”12” 14” 22” 24”

3”D X 5”L WINGS

CONTINUE ON NEXT PAGE FOR LARGER WINGS

1 SIZE & COVER

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

Pride recommends a gap between the seat pan and bottom of the backrest. Static or Tilt chair gap (3-4 inches) Recline or Tilt/Recline chair gap (6-7 inches) Comfort Company has built this recom-mended gap into the mounting bracket for TB3 chairs to achieve the target back height. Additional adjustments may be made to the chair by changing the peg placement if desired.

BACKREST SIZE SELECTION

TB3-

AC

TA-B

AC

K-D

EE

P-F

OR

M R

EV

0116

BA

CK

RE

ST L

EN

GTH

BA

CK

RE

ST L

EN

GTH

*Length (L) refers to the actual size dimension of the support from bottom to top edge.

STATIC or TILT CHAIRS RECLINE or TILT/RECLINE CHAIRS

DESIRED BACK HEIGHT

(Seat pan to top of back shell)

RECOMMENDED CC BACKREST

LENGTH*

DESIRED BACK HEIGHT

(Seat pan to top of back shell)

RECOMMENDED CC BACKREST

LENGTH*

26-28 in. 27-28 in. 22

24-25 in. 22 25-26 in. 20

22-23 in. 20 23-24 in. 18

20-21 in. 18 21-22 in. 16

18-19 in. 16 19-20 in. 14

16-17 in. 14 17-18 in. 12

14-15 in. 12 15-16 in.

BACK OPTIONS22.1

COLOR ACCENT

SILVER REFLECTIVE PIPING COMES STANDARD

Red (RED) Blue (BLUE)

Purple (PURPLE) Green (GREEN)

Pink (PINK) Remove (REMOVE)

2.2 EMBROIDERY*

WORD ONE

THREAD COLOR OPTIONS

Red (EMB-RED) Blue (EMB-BLUE)

Purple (EMB-PURPLE) Green (EMB-GREEN)

Pink (EMB-PINK) Silver (EMB-SILVER)

WORD TWO

- AND/OR -

A.

B.

C.

MSRP $25.00 MSRP $25.00 MSRP $35.00

FONT/STYLE OPTIONSHelvetica (EMB-Helvetica) (EMB-Twilight)

Garamond (EMB-Garamond) (EMB-Script)

*ADDITIONAL LEAD TIMES MAY APPLY

2.3PRIVACY FLAP

Privacy Flap (PV-FLAP)

This flap connects with hook/loop attachment between the seat and back for added privacy.

Privacy Flap

ORDER FORM 2 of 3Patient Reference:ACTA-BACK DEEP TB3 ORDER FORM

COLOR LOCATION

FRAME WIDTH

BK-M7D-22FP3-16

BK-M7D-22FP3-18

BK-M7D-22FP3-20

BK-M7D-22FP3-22

BK-M7D-22FP3-24

BK-M7D-20FP3-14

BK-M7D-20FP3-16

BK-M7D-20FP3-18

BK-M7D-20FP3-20

BK-M7D-20FP3-22

BK-M7D-20FP3-24

BK-M7D-18FP3-14

BK-M7D-18FP3-16

BK-M7D-18FP3-18

BK-M7D-18FP3-20

BK-M7D-18FP3-22

BK-M7D-18FP3-24

BK-M7D-16FP3-14

BK-M7D-16FP3-16

BK-M7D-16FP3-18

BK-M7D-16FP3-20

BK-M7D-16FP3-22

BK-M7D-14FP3-16

BK-M7D-14FP3-18

BK-M7D-14FP3-20

BK-M7D-12FP3-16

BK-M7D-12FP3-18

16”

18”

20”

16” 18” 20” 22”

$60100 $67700

12” 14”

14”

12”

24”

22”

$67800 $75400

16” 18” 20”12” 14” 22” 24”

FRAME WIDTH

BK-M7D-22UP3-16

BK-M7D-22UP3-18

BK-M7D-22UP3-20

BK-M7D-22UP3-22

BK-M7D-22UP3-24

BK-M7D-20UP3-14

BK-M7D-20UP3-16

BK-M7D-20UP3-18

BK-M7D-20UP3-20

BK-M7D-20UP3-22

BK-M7D-20UP3-24

BK-M7D-18UP3-14

BK-M7D-18UP3-16

BK-M7D-18UP3-18

BK-M7D-18UP3-20

BK-M7D-18UP3-22

BK-M7D-18UP3-24

BK-M7D-16UP3-14

BK-M7D-16UP3-16

BK-M7D-16UP3-18

BK-M7D-16UP3-20

BK-M7D-16UP3-22

BK-M7D-14UP3-16

BK-M7D-14UP3-18

BK-M7D-14UP3-20

BK-M7D-12UP3-16

BK-M7D-12UP3-18

16”

18”

20”

16” 18” 20” 22”

$60100 $67700

12” 14”

14”

12”

24”

22”

$67800 $75400

16” 18” 20”12” 14” 22” 24”

7”D X 7”L WINGS

STRETCH AIR COMFORT TEK

FRAME WIDTH

BK-M5D-22FP3-16

BK-M5D-22FP3-18

BK-M5D-22FP3-20

BK-M5D-22FP3-22

BK-M5D-22FP3-24

BK-M5D-20FP3-14

BK-M5D-20FP3-16

BK-M5D-20FP3-18

BK-M5D-20FP3-20

BK-M5D-20FP3-22

BK-M5D-20FP3-24

BK-M5D-18FP3-14

BK-M5D-18FP3-16

BK-M5D-18FP3-18

BK-M5D-18FP3-20

BK-M5D-18FP3-22

BK-M5D-18FP3-24

BK-M5D-16FP3-14

BK-M5D-16FP3-16

BK-M5D-16FP3-18

BK-M5D-16FP3-20

BK-M5D-16FP3-22

BK-M5D-14FP3-12

BK-M5D-14FP3-14

BK-M5D-14FP3-16

BK-M5D-14FP3-18

BK-M5D-14FP3-20

BK-M5D-12FP3-12

BK-M5D-12FP3-14

BK-M5D-12FP3-16

BK-M5D-12FP3-18

16”

18”

20”

16” 18” 20” 22”

$60100 $67700

12” 14”

14”

12”

24”

22”

$67800 $75400

16” 18” 20”12” 14” 22” 24”

FRAME WIDTH

BK-M5D-22UP3-16

BK-M5D-22UP3-18

BK-M5D-22UP3-20

BK-M5D-22UP3-22

BK-M5D-22UP3-24

BK-M5D-20UP3-14

BK-M5D-20UP3-16

BK-M5D-20UP3-18

BK-M5D-20UP3-20

BK-M5D-20UP3-22

BK-M5D-20UP3-24

BK-M5D-18UP3-14

BK-M5D-18UP3-16

BK-M5D-18UP3-18

BK-M5D-18UP3-20

BK-M5D-18UP3-22

BK-M5D-18UP3-24

BK-M5D-16UP3-14

BK-M5D-16UP3-16

BK-M5D-16UP3-18

BK-M5D-16UP3-20

BK-M5D-16UP3-22

BK-M5D-14UP3-12

BK-M5D-14UP3-14

BK-M5D-14UP3-16

BK-M5D-14UP3-18

BK-M5D-14UP3-20

BK-M5D-12UP3-12

BK-M5D-12UP3-14

BK-M5D-12UP3-16

BK-M5D-12UP3-18

16”

18”

20”

16” 18” 20” 22”

$60100 $67700

12” 14”

14”

12”

24”

22”

$67800 $75400

16” 18” 20”12” 14” 22” 24”

STRETCH AIR COMFORT TEK

5”D X 6”L WINGS

TB3-

AC

TA-B

AC

K-D

EE

P-F

OR

M R

EV

0116

BA

CK

RE

ST L

EN

GTH

BA

CK

RE

ST L

EN

GTH

BA

CK

RE

ST L

EN

GTH

BA

CK

RE

ST L

EN

GTH

*Length (L) refers to the actual size dimension of the support from bottom to top edge.

ORDER FORM 3 of 3Patient Reference:ACTA-BACK DEEP TB3 ORDER FORM

TB3-

AC

TA-B

AC

K-D

EE

P-F

OR

M R

EV

0116

BODI-LINK HEAD SUPPORT & HARDWARE3

COMFORT TEK FOR FLUID PROTECTION & AN EASILY CLEANED

SURFACE.

FOR AIR TRANSMISSION & HEAT DISSIPATION.

NOT FLUID RESISTANT.

STRETCH AIR

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

L

L

L

L

L

W

W

Extra Link

Extra Spacer Plate

¼”

3.3 HEAD SUPPORT HARDWAREHCPCS CODING: E1028

MSRP $221.00/ea. MSRP $35.00/extra link or spacer each

3.2 PAD COVER MATERIAL

GlideWear® (GLIDEWEAR)

Comfort-Tek (COMFORT-TEK)

Stretch-Air (STRETCH-AIR)

Removable Hardware (BL-HSH-FX)

Extra Link (BL-HSH-LINK)

Extra Spacer Plate (BL-HSH-SPCR)

Length (L) refers to the actual size dimension of the support from bottom to top edge.

HEAD SUPPORT PAD STYLEHCPCS CODING: E0955 MSRP $230.00

3.1

3 ¼”

Pad Firmness

6W x 3½LSoft BL-HSP1-6W3L

Extra Soft BL-HSP2-6W3L

8W x 4LSoft BL-HSP1-8W4L

Extra Soft BL-HSP2-8W4L

10W x 5Lwith adjustable wings

Soft BL-HSP1-10W5L

Extra Soft BL-HSP2-10W5L

14W x 5Lwith adjustable wings

Soft BL-HSP1-14W5L

Extra Soft BL-HSP2-14W5L

18W x 5Lwith adjustable wings

Soft BL-HSP1-18W5L

Extra Soft BL-HSP2-18W5L

Patent Pending