Silhouette Custom BasicForm 07-030 Revised 5-1-12

Send Order to: Pindot, 899 Cleveland St. Elyria, OH 44036 or V2.3

fax to: 800-834-4153 or Email to:

Invacare Wheelchair Order Form Being Sent With This Order: If Yes:

Seat Cushion Order Form Cushion Firmness: $835.00

.SM2 * Go to Page 2

for internal use:Gender: Patient Width at Hips: inches

Cushion Width: inchesCushion Length: inches

* Measure length from the seat back to the place on the client's thigh where the cushion is to end, plus an additional 1"

Growth Option: inches * Enter in 1/2" increments, up to 23" cushion depthAdditional Deepening: inches * Enter in .01" increments, up to 1.5" max.Shift Contour: inches * Enter in .06" increments, up to 4" max.Additional Minimum Thickness: inches * Default minimum cushion thickness is 1.45"

Leg Troughs: inches * Amount to deepen or reduce template leg trough, in 1/4" incrementsRaise Right Lateral Thigh Support - Width: inches Height: inches From front, extended back: inchesRaise Left Lateral Thigh Support - Width: inches Height: inches From front, extended back: inchesIncrease Medial Thigh Support - Width: inches Height: inches Depth: inches

Radius: Taper:

Roll: Wedge: inches:

Comments or Special Instructions

Seat Cushion ModificationsLeg Length Discrepancy (SO90) Shorten by: inches $65.00

* Longer Leg will be Cushion Length Indicated Above

Location for recess or Sofspot : Front edge of recess to be inches from front of cushion Left edge of recess to be inches from left edge of cushion

Size of Recess: Width: inches Length: inches Depth:

Type of Recess: $95.00 $150.00$210.00 $250.00

* Note: If recess is for an air bladder, indicate location of valve (i.e. right-rear or left-front, etc.) in Comments box

Rail Cut Options: $65.00 $65.00

Purchase Order #:

Seat Design

variable from 8" to 23". Additional cost for width or length larger than 20". $65.00

For ease of ordering, contact Pindot Customer Service Toll Free at:

800-451-3553

Company Name:Contact Name:

{

Ship to Address:

Account #:City/State/Zip:

ElyriaCustomSeating@invacare.com

Phone Number:

Fax Number:Cell Phone #:

E-mail Address:Date:

Client Reference:

SN#

Yes No With Chair On Chair

Soft Firm Extra Firm

Male Female

Deepen Reduce

Right or Left

0 inches1 inches2 inches3 inches

4 inches (Std)

0 inches (Std)1 inches2 inches

0 inches1 inches (Std)2 inches

Front to BackBack to FrontLeft to RightRight to Left

1 inch 2 inchesRecess Only (CM30) Sofspot - Std Foam (CM09)

Sofspot - Visco Foam (CM09V)Gel Insert (CM30G)

Left Leg Right Leg

Standard 1" Wide x 2" Deep for Infinity Drop BaseOther: for ContourU Pan

User Design File Included with Order - File Name:Apply Design Specifications Listed Below

None

None

None

$65.00 in. Wide x in. Deep $65.00

$65.00$60.00

Seat Mounting W x D (TFEP) $240.00

W x D $195.00 $240.00$195.00 $291.00$135.00

If Wood Mount Selected, Specify Cover Type

Seat Mounting Hardware$205.00 $205.00$205.00 $205.00

Removable Seat Covers

Additional Removable Seat Covers(Waterproof - Inner cover) $190.00

$190.00

Comments or Special Instructions

Back Cushion Order Form

Cushion Firmness: $835.00

.SM2 * Go to Page 4

Patient Chest Width: inches * Cushion width minus thickness of both laterals should approx. = chest width

Cushion Width: inchesCushion Length: inches

* Note: Minimum thickness will be 1.5"

Trunk Lateral Height Left: inches Lateral Depth Left: inches Lateral Thickness Left: inches Right: inches Right: inches Right: inches

* As measured from deepest part of back

{ variable from 8" to 24". Additional cost for width or length larger than 20". $65.00

Invacare Corporation, One Invacare Way, Elyria, OH USA 44036-2125

PinDot, Silhouette and ContourU are registered trademarks of Invacare.

Specifications are subject to change without notification.

Back Design

* Unless specified otherwise, seat cushions will have flat bottom and Hook & Loop Velcro Mount

Other: for ContourU Pan

Undercut (SO77)

Solid Wood Insert - Used for Sling Reduction (SO92)

Fit Existing ContourU Pan: Fit New ContourU Pan: Wood Mount with T-Nuts (CM06T) Wood Mount without T-Nuts (CM06)

Infinity Drop Base 14" - 16" Wide (IDB/SM)Infinity Drop Base 17" - 19" Wide (IDB/MD)Infinity Drop Base 20" - 22" Wide (IDB/LR)Other:

Draw String Zippered 2 Piece Velcro

Polartek (PLRTK)Lycra (LYCRA)Darlexx (DARLEX)Standard Dartex (DT-2)Reversed Dartex (DT-2R)

Gray Rubber Backed Lycra (L-06)

Black Rubber Backed Lycra (L-05)Red Rubber Backed Lycra (L-14)Teal Rubber Backed Lycra (L-15)Light Blue Rubber Backed Lycra (L-13)Purple Rubber Backed Lycra (L-18)

Burgundy Rubber Backed Lycra (L-19)

Blue Rubber Backed Lycra (L-20)Green Rubber Backed Lycra (L-23)

Inner Recovery Cover (SO40)Additional Fabric Cover (SO25) Fabric:

None

None

None HWWMK01 HWWMK78HWPMK01 HWPMK78

Soft Firm Extra Firm

User Design File Included with Order - File Name:Apply Design Specifications Listed Below

Back Cushion ModificationsLocation for recess or Sofspot: Bottom edge of recess to be inches from bottom of cushion

Left edge of recess to be inches from left edge of cushion

Size of Recess: Width: inches Length: inches Depth:Type of Recess: $95.00 $150.00

$210.00 $250.00* Note: If recess is for an air bladder, indicate location of valve (i.e. right-rear or left-front, etc.) in Comments box

Rail Cut Options: $65.00$65.00$65.00

inches Wide x inches Deep $65.00$65.00

inches

inches

* From Bottom of Cushion

Back Mounting W x D (TFEP) $195.00

W x D (TFNP) $195.00 $135.00$65.00 If Wood Mount Selected, Specify Cover Type

$400.00$500.00 Wheelchair Frame Width inches (Variable 12" - 24")

Back Mounting Hardware$205.00 $205.00 $260.00$205.00 $205.00

Removable Back Covers

Additional Removable Back Covers(Waterproof - Inner cover) $190.00

$190.00

Accessories$322.00$322.00$322.00$322.00$120.00$110.00$110.00 $110.00

* Unless specified otherwise, back cushion will have flat bottom, Hook & Loop Velcro Mount and 4" Curved Top

KwikFit Includes: Shell, Angle Adjustable Interfacing Hardware, Attachment Points for Pindot Headrest, and a Custom Sewn Cover. KwikFit Mounting for Backs will Fit Between the Wheelchair Canes. Cushion and Shell will be Made 2 1/2" Smaller than Wheelchair Width Indicated. Standard KwikFit Mounted Back will have a 2" curved Top.

1 inch 2 inchesRecess Only (CM30) Sofspot - Std Foam (CM09)

Sofspot - Visco Foam (CM09V)Gel Insert (CM30G)

Standard 1" Wide x 2" Deep (SO75)

for KwikFit (SO78)Other:

for ContourU Pan (SO74)

Fit Existing ContourU Pan: Fit New ContourU Pan:

Wood Mount with T-Nuts (CM06T) Wood Mount without T-Nuts (CM06)

Tarsys - Curved Back - 2nd Generation Formula - Contoura

Other:

Draw String Zippered 2 Piece Velcro

Polartek (PLRTK)Lycra (LYCRA)Darlexx (DARLEX)Standard Dartex (DT-2)Reversed Dartex (DT-2R)

Gray Rubber Backed Lycra (L-06)

Black Rubber Backed Lycra (L-05)Red Rubber Backed Lycra (L-14)Teal Rubber Backed Lycra (L-15)Light Blue Rubber Backed Lycra (L-13)Purple Rubber Backed Lycra (L-18)

Burgundy Rubber Backed Lycra (L-19)

Blue Rubber Backed Lycra (L-20)Green Rubber Backed Lycra (L-23)

Inner Recovery Cover (SO40)Additional Fabric Cover (SO25) Fabric:

None

None

None HWWMK01HWWMK78

HWABKHWPMK01HWPMK78

I-Cut, as indicated below (SO76)

Formula - ConventionalPersonal Back Shell

KwikFit Mounting for Backs (SKF30)

Small Headrest with Adapter Plate (HR01S)Large Headrest with Adapter Plate (HR02S)2-Step Headrest with Adapter Plate (HR03S)Curved Headrest with Adapter Plate (HR04S)Extended Back Mounting Brackets (SMB03)Lateral Insert Replacement Set (SL10S)

Straight Lateral - Left (SLK00)**1/2" Offset Lateral - Left (SLK05)**

Straight Lateral - Right (SRK00)**1/2" Offset Lateral - Right (SRK05)**

$110.00 $110.00$110.00 $110.00$110.00 $110.00

** Laterals Fit the Silhouette KwikFit Shell OnlyNote: All Silhouette accessories are available with the Custom Basic. If an accessory is not listed above, write it in the comments below

Comments or Special Instructions

Invacare Corporation, One Invacare Way, Elyria, OH USA 44036-2125

PinDot, Silhouette and ContourU are registered trademarks of Invacare.

Specifications are subject to change without notification.

Straight Lateral - Left (SLK00)**1/2" Offset Lateral - Left (SLK05)**1" Offset Lateral - Left (SLK10)**1 1/2" Offset Lateral - Left (SLK15)**

Straight Lateral - Right (SRK00)**1/2" Offset Lateral - Right (SRK05)**1" Offset Lateral - Right (SRK10)**1 1/2" Offset Lateral - Right (SRK15)**