acta-relief order form - permobil · acta-relief™ order form patient reference: page 1 of 7...

SIZE SELECTION1

ACTA-RELIEF™

ORDER FORMPRICING IN CANADIAN DOLLARS Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

Shown with Compass® 4 Quick Release 2 Point Hardware. Cover appearance may vary with hardware selection.

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

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ACTA-RELIEF™ ORDER FORM Patient Reference: PAGE 1 of 7

Required

20”

20”

20”

LEN

GTH

*

FRAME WIDTH

16” 18” 20”14”

BASE MSRP $1,096.25

LEN

GTH

*

FRAME WIDTH

14W22L 16W22L 18W22L 20W22L

14W20L 16W20L 18W20L 20W20L

14W18L 16W18L 18W18L 20W18L

14W16L 16W16L 18W16L 20W16L

14W14L 16W14L 18W14L 20W14L

14W12L 16W12L 18W12L 20W12L

14W10L 16W10L 18W10L 20W10L

14W22L 16W22L 18W22L 20W22L

14W20L 16W20L 18W20L 20W20L

14W18L 16W18L 18W18L 20W18L

14W16L 16W16L 18W16L 20W16L

14W14L 16W14L 18W14L 20W14L

14W12L 16W12L 18W12L 20W12L

14W22L 16W22L 18W22L 20W22L

14W20L 16W20L 18W20L 20W20L

14W18L 16W18L 18W18L 20W18L

14W16L 16W16L 18W16L 20W16L

14W14L 16W14L 18W14L 20W14L

14W12L 16W12L 18W12L 20W12L

16”

16”

16”

18”

18”

18”

16”

16”

16”

18”

18”

18”

20”

20”

20”

14”

14”

14”

14”

14”

14”

10”

10”

10”

12”

12”

12”

22”

22”

22”

Sizes available with 2 POINT Mounting Hardware

LEN

GTH

*

FRAME WIDTH

Sizes available with 4 POINT Mounting Hardware

LEN

GTH

*

FRAME WIDTH

Sizes available with POWER Mounting Hardware

Please fill in one of the above with dimensions from the size charts to the right.Example Part: AR-BS14W16L

Hardware will be selected in Section 2.

Sizes available are subject to hardware being used.

IF DESIRED SIZE IS NOT LISTED, PLEASE CONTACT

CUSTOMER SERVICE FOR ASSISTANCE. | 800.265.9830

AR-BS

16”

18”

20”

14”

12”

10”

22”

Acta-Relief Patent Pending

14W10L 16W10L 18W10L 20W10L

14W12L 16W12L 18W12L 20W12L

Please note these sizes are not available with lateral trunk supports or a head support.

Please note these sizes are not available with 4 POINT when using lateral trunk supports.

For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then email or print and fax to Customer Service at [email protected] or 1.877.636.8944

COVER & HARDWARE SELECTION2 Required

2.1

2.2

COVER SELECTION

HARDWARE STYLE

MSRP $0.00

Price included in back support purchase Price included in back support purchase MSRP add $78.13

Latex-free fabric. Fabric selection is for the support surface only. Other fabrics used in cover construction remain the same.

STRETCH-AIR™ Cover (STRETCH-AIR)

QUICK RELEASE 2 POINT (Q-COMPASS)

FIXED 2 POINT(NQ-COMPASS)

QUANTUM w/ TRU BALANCE 3(PMB-QUANTUM)

QUICK RELEASE 4 POINT(Q-COMPASS4)

FIXED 4 POINT(NQ-COMPASS4)

PERMOBIL w/ CORPUS 3G(PMB-PERMOBIL)

QUICKIE w/ 3.7 POWER(PMB-QUICKIE)

AVID REHAB w/ POWER T & R(PMB-AVID)

ROVI w/ MOTION CONCEPTS*(PMB-ROVI)

TOP VIEW

STRETCH-AIR™ has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant.

FIXED fully adjustable hardware requires tools for back support removal

4 POINT hardware is required on all 24”W back supports using Compass® 4 hardware.

POWER MOUNT hardware has 8” of height adjustment in ½” increments without using tools.

COMPASS® 4 QUICK RELEASE COMPASS® 4 FIXED COMPASS® POWER MOUNT

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*Using Power Mount Hardware on ROVI requires mounting to the RECESSED PLANAR INTERFACE

PLATE available when ordering the Motion Concepts Seating System. Drilling is required for mounting.

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BODILINK® LATERAL TRUNK SUPPORT & HARDWARE3

Contact Customer Support for custom sizes. 1.800.564.9248.

Continue on next page for cover selection (section 4.3) if basic style pads are selected.

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.1.• Follow each column down to sections 3.2 and 3.3 (next page) and select a style and cover for each pad selected in section 3.1. Premium pads in section 3.4 on next page.

3.1

3.2

BASIC PAD SIZE & SHAPE

BASIC PAD STYLE

MSRP $145.83/ea.

MSRP $0.00/ea.

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

SHAPE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

SUP

PO

RTI

VE

3”L x 4”D BL-LTSP1S-3L4D-LH BL-LTSP1S-3L4D-LH BL-LTSP1S-3L4D-RH BL-LTSP1S-3L4D-RH






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3”L x 4”D BL-LTSP1A-3L4D-LH BL-LTSP1A-3L4D-LH BL-LTSP1A-3L4D-RH BL-LTSP1A-3L4D-RH






STYLE OPTIONS LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

MOLDABLE LTS-P1-MOLD LTS-P1-MOLD LTS-P1-MOLD LTS-P1-MOLD

RIGID LTS-P1-RIGID LTS-P1-RIGID LTS-P1-RIGID LTS-P1-RIGID

ACTIVE

SUPPORTIVE

OR

OR

OR

L

L

D

D

RIGIDMOLDABLE

*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations. Please contact customer support with questions.

3.3 BASIC PAD COVERMSRP $0.00/ea.

COVER OPTIONS LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

STRETCH-AIR™ LTS-P1-STRETCH LTS-P1-STRETCH LTS-P1-STRETCH LTS-P1-STRETCH

STRETCH-AIR™FOR AIR TRANSMISSION

& HEAT DISSIPATION.

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.4.• Follow each column down to sections 3.5 and 3.6 and select a style and cover for each pad selected in section 3.4.

3.4 PREMIUM PAD SIZE & SHAPEMSRP $197.92/ea.

*Length (L) refers to the dimension of the support from top to bottom edge. Depth (D) refers to the dimension of the support from anterior to posterior edge.

SHAPE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

SUP

PO

RTI

VE


3”L x 5.5”D BL-LTSP2S-3L5D-LH BL-LTSP2S-3L5D-LH BL-LTSP2S-3L5D-RH BL-LTSP2S-3L5D-RH





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3”L x 5.5”D BL-LTSP2A-3L5D-LH BL-LTSP2A-3L5D-LH BL-LTSP2A-3L5D-RH BL-LTSP2A-3L5D-RH





SUPPORTIVE

ACTIVE

OR

L

L

D

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3.5

3.6

PREMIUM PAD STYLE

PREMIUM PAD COVER

MSRP $0.00/ea.

COVER OPTIONS MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

NO COVER $0.00/ea. LTS-P2-NO-CV LTS-P2-NO-CV LTS-P2-NO-CV LTS-P2-NO-CV

STRETCH-AIR™ $0.00/ea. LTS-P2-STRETCH LTS-P2-STRETCH LTS-P2-STRETCH LTS-P2-STRETCH

GLIDEWEAR® $67.71/ea. LTS-P2-GLIDE LTS-P2-GLIDE LTS-P2-GLIDE LTS-P2-GLIDE

STRETCH-AIR™ with FOAM $26.04/ea. LTS-P2-STRETCH-FM LTS-P2-STRETCH-FM LTS-P2-STRETCH-FM LTS-P2-STRETCH-FM

GLIDEWEAR® with FOAM $93.75/ea. LTS-P2-GLIDE-FM LTS-P2-GLIDE-FM LTS-P2-GLIDE-FM LTS-P2-GLIDE-FM

STYLE OPTIONS LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

MOLDABLE LTS-P2-MOLD LTS-P2-MOLD LTS-P2-MOLD LTS-P2-MOLD

RIGID LTS-P2-RIGID LTS-P2-RIGID LTS-P2-RIGID LTS-P2-RIGID

OR

OR

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

STRETCH-AIR™ COVER with FOAMFOR AIR TRANSMISSION

& HEAT DISSIPATION.

FOR SOFT FEEL, NON-ZERO CUSHIONING SUPPORT.

RIGIDMOLDABLE

*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations. Please contact customer support with questions.

Both Fixed and Swing-Away hardware styles are adjustable.

3.7 GTMOUNTING HARDWARE

SLOT MOUNTING MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

SWING-AWAY $218.75/ea. BL-LTS-GT1SAK-LH BL-LTS-GT1SAK-LH BL-LTS-GT1SAK-RH BL-LTS-GT1SAK-RH

FIXED $145.83/ea. BL-LTS-GT1FXK-LH BL-LTS-GT1FXK-LH BL-LTS-GT1FXK-RH BL-LTS-GT1FXK-RHOR

SWING-AWAY FIXED

Open Position

Release Button

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.7.

• GT and GT2 Hardware and Pad styles are interchangeable.

*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations.

SLOT MOUNTING MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

SWING-AWAY $333.33/ea. BL-LTS-GT2SAK-LH BL-LTS-GT2SAK-LH BL-LTS-GT2SAK-RH BL-LTS-GT2SAK-RH

FIXED $182.29/ea. BL-LTS-GT2FXK-LH BL-LTS-GT2FXK-LH BL-LTS-GT2FXK-RH BL-LTS-GT2FXK-RHOR

SWING-AWAY FIXED

Both Fixed and Swing-Away hardware styles are adjustable.

3.8GT2 MOUNTING HARDWARE

Open Position

Release Button

• You may make one selection per column in section 3.8.

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14W x 5L Head Support Pad Pictured

BODILINK® HEAD SUPPORT HARDWARE & PADS3

FOR AIR TRANSMISSION & HEAT DISSIPATION.

STRETCH-AIR

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

L

3.2 PREMIUM PAD COVER MATERIAL

GlideWear® (GLIDEWEAR) (add $78.13)

Stretch-Air (STRETCH-AIR)

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

PREMIUM PAD SIZE MSRP $235.00

4.1

Premium Head Support Pads angles can be

formed by adjusting the plates in the pad.

• You may make one selection per column.• Choose between premium (3.1) -or- basic (3.3).• Choose a cover material in 3.2 -or- 3.4.

W

W

Pad Firmness

L

L

L

L

L

FOR AIR TRANSMISSION & HEAT DISSIPATION.

STRETCH-AIR

3.4 BASIC PAD COVER MATERIAL

Stretch-Air (STRETCH-AIR)

Basic head support pads can be formed

to any shape using the moldable steel insert

inside the pad.

BASIC PAD SIZEMSRP $235.00

3.3

6W x 5L BL-HSP3-6W5L






L

L

L

L

L

L

W

W

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

3.5 HEAD SUPPORT HARDWARE

SIZE & SHAPE MSRP PART NUMBER

MID 6 $338.54 (BL-HS-PT1RMMID6)

LAT 6 $442.71 (BL-HS-PT1RMLAT6)

MID 8 $338.54 (BL-HS-PT1RMMID8)

LAT 8 $442.71 (BL-HS-PT1RMLAT8)

MAX 8* $494.79 (BL-HS-PT1RMMAX8)

*Provides the greatest amount of articulation and range of motion.

PT HARDWARE, REMOVABLEA.

PT

HA

RD

WA

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, M

ID 6

PT

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RD

WA

RE

, L

AT

6

PT

HA

RD

WA

RE

, M

ID 8

PT

HA

RD

WA

RE

, L

AT

8

PT

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AX

8

• You may make one selection per column in either A -or- B.• If choosing 3.5 A, choose a stem length option next.• Choose which mounting block option you require in 3.6.

PT MODEL

TOTAL # OF

LINKS

TOTAL LINK

LENGTH

MAX. ANTERIOR

REACH

MAX. POSTERIOR

REACH

MAX. LATERAL REACH

MID 6 2 6” 5.5” 1” N/A

LAT 6 3 6” 5.5” 1” 6”

MID 8 2 8” 7.5” 1” N/A

LAT 8 3 8” 7.5” 1” 8”

MAX 8 4 8” 7.5” 3” 8”

PT HARDWARE RANGE OF MOTION

6W x 3LSoft BL-HSP1-6W3L

Extra Soft BL-HSP2-6W3L

8W x 4LSoft BL-HSP1-8W4L


10W x 5Lwith adjustable wings

Soft BL-HSP1-10W5L



Soft BL-HSP1-12W5L



Soft BL-HSP1-14W5L



Soft BL-HSP1-18W5L


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SIZE & SHAPE MSRP PART NUMBER

LATERAL $317.71 (BL-HS-GT3RMLAT)

MID-LINE $281.25 (BL-HS-GT3RMMID)

GT HARDWARE, REMOVABLEB.

GT

HA

RD

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AL

GT

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RD

WA

RE

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ID-L

INE

GT MODEL

TOTAL # OF

LINKS

TOTAL LINK

LENGTH

MAX. ANTERIOR

REACH

MAX. POSTERIOR

REACH

MAX. LATERAL REACH

LAT 5 10.5” 10” 2” 7.5”

MID 3 8.5” 8” 2” N/A

GT HARDWARE RANGE OF MOTION

MOUNTING BLOCK OR BRACKET WITH BLOCK MSRP PART NUMBER

*ACTA-RELIEF™ 14W BRACKET WITH MOUNTING BLOCK $145.83 (HS-MB-AR14W)




POSTERIOR A MOUNTING BLOCK $0.00 (HS-MB-POSTA)

3.6 HEAD SUPPORT MOUNTING OPTION

MOUNTING BLOCK-POSTERIOR A

For Acta-Relief with Power Mount Only

STEM LENGTH MSRP PART NUMBER

STANDARD 7” STEM $0.00 (HS-STEM-7)

***3” STEM $0.00 (HS-STEM-3)

PT HARDWARE, STEM LENGTH OPTION

ST

AN

DA

RD

P

T S

TE

M, 7

”

PT

ST

EM

, 3

”

***3” Stem is recommended for use with power mounting where there may be special constraints with power chair functions

PT HARDWARE (CONTINUED)

BRACKET WITH MOUNTING BLOCK-

ACTA-RELIEF™18W Shown Above

For Non-Power Mount Only.

*For Acta Relief™, includes mounting bracket and POSTA block. If you already have an Acta-Relief™ head support bracket, order POSTA Block

acta-relief order form - permobil · acta-relief™ order form patient reference: page 1 of 7...

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