company name/acct #: custom inception seat...

4” D (CD-AT-DEPTH-4)













OTHER (CD-AT-DEPTH-OTHER)

1/5CD-INCEPTION-SHORTFORM REV0518

7 ANTI-THRUST5 SHAPE $0.00

6 BOTTOM STYLE

3 INCONTINENCE LINER

4 EXTRA COVER

2 COVER MATERIAL OPTIONS

Notes: Anti-Thrust depth will be half of the seat depth unless otherwise specified.

Depth dimension is before growth kit strips are applied.

A.

A.

B.SIDE VIEW

SIDE VIEW

SIDE VIEW

H

H

D

Choose one style and a height from directly below your style choice.

ANTI-THRUST

ANTI-THRUST DEPTH $0.00

ANTI-THRUST WITH GROWTH KIT $0.00

COMFORT-TEK™

COMFORT-TEK™

WEDGE $35.00

STRETCH-AIR™

STRETCH-AIR™

ANTI-THRUST $0.00

HEIGHT½” H (CD-AT-GK-HEIGHT-0.5)

1” H (CD-AT-GK-HEIGHT-1.0)

1½” H (CD-AT-GK-HEIGHT-1.5)

2” H (CD-AT-GK-HEIGHT-2.0)

2½” H (CD-AT-GK-HEIGHT-2.5)

OTHER (CD-AT-GK-HEIGHT-OTHER)

WEDGE HEIGHT1” H (CD-WEDGE-1)

2” H (CD-WEDGE-2)

3” H (CD-WEDGE-3)

OTHER (CD-WEDGE-OTHER)

HEIGHT½” H (CD-AT-HEIGHT-0.5)

1” H (CD-AT-HEIGHT-1.0)

1½” H (CD-AT-HEIGHT-1.5)

2” H (CD-AT-HEIGHT-2.0)

2½” H (CD-AT-HEIGHT-2.5)

OTHER (CD-AT-HEIGHT-OTHER)

STYLESTANDARD ANTI-THRUST WITH GROWTH KIT (CD-AT-STND-GROWTH-KIT)

Anti-Thrust with (3) 1” strips included for growing the Anti-Thrust depth. Top layer foam is not glued in the seat well allowing access to the 1” pieces.

STYLESTANDARD ANTI-THRUST (CD-AT-STANDARD)

LEFT SIDE ONLY (CD-AT-LEFT)

RIGHT SIDE ONLY (CD-AT-RIGHT)

WEDGE STYLESTANDARD FULL WEDGE (CD-WEDGE-STANDARD)

STANDARD LEFT SIDE ONLY (CD-WEDGE-LEFT)

STANDARD RIGHT SIDE ONLY (CD-WEDGE-RIGHT)

REVERSE FULL WEDGE (CD-WEDGE-REV)

REVERSE LEFT SIDE ONLY (CD-WEDGE-REV-LEFT)

REVERSE RIGHT SIDE ONLY (CD-WEDGE-REV-RIGHT)

STANDARD $83.00DIAMOND ACCENT (CD-X-COMFORT-TEK)

DIGI-CAMO ACCENT (CD-DIGI-X-COMFORT-TEK)

w/ GLIDEWEAR® $105.00DIAMOND ACCENT (CD-GW-X-COMFORT-TEK)

DIGI-CAMO ACCENT (CD-DIGI-GW-X-COMFORT-TEK)

STANDARD $0.00DIAMOND ACCENT (CD-COMFORT-TEK)

DIGI-CAMO ACCENT (CD-DIGI-COMFORT-TEK)

w/ GLIDEWEAR® $23.00DIAMOND ACCENT (CD-GW-COMFORT-TEK)

DIGI-CAMO ACCENT (CD-DIGI-GW-COMFORT-TEK)

STANDARD $83.00DIAMOND ACCENT (CD-X-STRETCH-AIR)

DIGI-CAMO ACCENT (CD-DIGI-X-STRETCH-AIR)

w/ GLIDEWEAR® $105.00DIAMOND ACCENT (CD-GW-X-STRETCH-AIR)

DIGI-CAMO ACCENT (CD-DIGI-GW-X-STRETCH-AIR)

STANDARD $0.00DIAMOND ACCENT (CD-STRETCH-AIR)

DIGI-CAMO ACCENT (CD-DIGI-STRETCH-AIR)

w/ GLIDEWEAR® $23.00DIAMOND ACCENT (CD-GW-STRETCH-AIR)

DIGI-CAMO ACCENT (CD-DIGI-GW-STRETCH-AIR)

ANTI-THRUST

ANTI-THRUST

with GROWTH KIT

ROUND (CD-ROUND-BOTTOM) $35.00

1/2” to 1” additional profile height will be added.

FLAT (CD-FLAT-BOTTOM) $0.00

Standard option if no bottom style is selected.

INCONTINENCE LINER $80.00(CD-INCON-LINER)

BUILD TO SPECIFICATION (CD-SHAPE-BUILD-2-SPEC)

ALL COMMON CUSHION SPECIFICATIONS ARE PRE-SELECTED. IF YOU DO NOT WISH TO ALTER THESE OPTIONS, YOU DO NOT HAVE TO MAKE ANY MORE SELECTIONS THROUGH THE REST OF THE FORM. HOWEVER, YOU MAY MODIFY ALL SPECIFICATIONS IN THEIR RESPECTIVE AREA OF THE ORDER FORM.

• Base Structure - Flat Bottom ¼” Crosslink• Lower Layer - 1” HR Medium• Middle Layer - ½” HR Soft • Topper Layer - ½” Viscool™ Soft

• Build to Specification has no predetermined values. You must continue by selecting any desired features in sections 6-22.

* REQUIRED *

* REQUIRED *

* REQUIRED *

ANTI-THRUST CONTOUR (CD-SHAPE-AT-CONTOUR)

FOAM LAYERS AS LISTED IN LINEAR, PLUS...

• Anti-Thrust - 1" H (15W and above)½ seat depth or ½" H (14W or below)

• Straight Adductors - 1 ½" H (15W and above)

or 1" H (14W or below)

• Abductor - 1 ½" H (15W and above)or 1" H (14W or below)

ANTI-THRUST (CD-SHAPE-ANTI-THRUST)


• Anti-Thrust - 1" H (15W and above)½ seat depth or ½" H (14W or below)

LINEAR (CD-SHAPE-LINEAR)

ZERO ELEVATION CONTOUR (CD-SHAPE-Z-ELEV-CONTOUR)


• Straight Adductors - 1 ½" H (15W and above)

or 1" H (14W or below)

• Abductor - 1 ½" H (15W and above)or 1" H (14W or below)

COMFORT-TEK™ provides incontinence protection and is an easily cleaned surface.

STRETCH-AIR™ provides air transmission and heat dissipation.

GLIDEWEAR® provides shear reduction and micro-climate control for enhanced skin protection and improved comfort.

DIAMOND & DIGI-CAMO are accent fabrics. Care is identical.

CUSTOM INCEPTION™ SEAT SUPPORT SURFACESHORT ORDER FORM

HCPCS CODE: E2609

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

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 to [email protected] or print and fax to 1.406.522.8563.

1 SIZE

C - C - W D10-20” Width / 10-18” Depth = $378.00 Base Price21-24” Width / 10-18” Depth = $474.00 Base Price10-24” Width / 19-22” Depth = $498.00 Base Price25-28” Width / 10-22” Depth = $952.00 Base Price*If desired size is not listed above, a 60% up charge will be applied for materials and Customer Support approval is required.

Contact Customer Support with questions 800.564.9248.

All custom requests should be added in “NOTES” section on page 4 along with the section number they are in reference to.Requests may require approval.


***ADDITIONAL LOWER LAYER ***ADDITIONAL MID LAYER ***ADDITIONAL TOPPER LAYERH.R. MEDIUM $0.00 H.R. MEDIUM $0.00 H.R. MEDIUM $0.00

1/4” (CD-ADD-LOW-HRM-0.25) 1/4” (CD-ADD-MID-HRM-0.25) 1/4” (CD-ADD-TOP-HRM-0.25)



1” (CD-ADD-LOW-HRM-1.00) 1” (CD-ADD-MID-HRM-1.00) 1” (CD-ADD-TOP-HRM-1.00)

1 1/4” (CD-ADD-LOW-HRM-1.25) 1 1/4” (CD-ADD-MID-HRM-1.25) 1 1/4” (CD-ADD-TOP-HRM-1.25)

OTHER (CD-ADD-LOW-HRM-OTHER) (3”Max) OTHER (CD-ADD-MID-HRM-OTHER) (2”Max) OTHER (CD-ADD-TOP-HRM-OTHER) (2”Max)

H.R. SOFT $0.00 H.R. SOFT $0.00 H.R. SOFT $0.001/4” (CD-ADD-LOW-HRS-0.25) 1/4” (CD-ADD-MID-HRS-0.25) 1/4” (CD-ADD-TOP-HRS-0.25)

1/2” (CD-ADD-LOW-HRS-0.50) 1/2” (CD-ADD-MID-HRS-0.50) 1/2” (CD-ADD-TOP-HRS-0.50)

3/4” (CD-ADD-LOW-HRS-0.75) 3/4” (CD-ADD-MID-HRS-0.75) 3/4” (CD-ADD-TOP-HRS-0.75)

1” (CD-ADD-LOW-HRS-1.00) 1” (CD-ADD-MID-HRS-1.00) 1” (CD-ADD-TOP-HRS-1.00)

1 1/4” (CD-ADD-LOW-HRS-1.25) 1 1/4” (CD-ADD-MID-HRS-1.25) 1 1/4” (CD-ADD-TOP-HRS-1.25)

OTHER (CD-ADD-LOW-HRS-OTHER) (3”Max) OTHER (CD-ADD-MID-HRS-OTHER) (2”Max) OTHER (CD-ADD-TOP-HRS-OTHER) (2”Max)

VISCOOL™ MEDIUM $138.00 VISCOOL™ MEDIUM $138.00 VISCOOL™ MEDIUM $138.00

1/2” (CD-ADD-LOW-VIS-M-0.50) 1/2” (CD-ADD-MID-VIS-M-0.50) 1/2” (CD-ADD-TOP-VIS-M-0.50)

1” (CD-ADD-LOW-VIS-M-1.00) 1” (CD-ADD-MID-VIS-M-1.00) 1” (CD-ADD-TOP-VIS-M-1.00)

OTHER (CD-ADD-LOW-VIS-M-OTHER) (3”Max) OTHER (CD-ADD-MID-VIS-M-OTHER) (2”Max) OTHER (CD-ADD-TOP-VIS-M-OTHER) (2”Max)

VISCOOL™ SOFT $138.00 VISCOOL™ SOFT $138.00 VISCOOL™ SOFT $138.00

1/2” (CD-ADD-LOW-VIS-S-0.50) 1/2” (CD-ADD-MID-VIS-S-0.50) 1/2” (CD-ADD-TOP-VIS-S-0.50)

1” (CD-ADD-LOW-VIS-S-1.00) 1” (CD-ADD-MID-VIS-S-1.00) 1” (CD-ADD-TOP-VIS-S-1.00)

OTHER (CD-ADD-LOW-VIS-S-OTHER) (3”Max) OTHER (CD-ADD-MID-VIS-S-OTHER) (2”Max) OTHER (CD-ADD-TOP-VIS-S-OTHER) (2”Max)

VISCOOL™ EXTRA SOFT $138.00 VISCOOL™ EXTRA SOFT $138.00 VISCOOL™ EXTRA SOFT $138.00

1/2” (CD-ADD-LOW-VIS-XS-0.50) 1/2” (CD-ADD-MID-VIS-XS-0.50) 1/2” (CD-ADD-TOP-VIS-XS-0.50)

1” (CD-ADD-LOW-VIS-XS-1.00) 1” (CD-ADD-MID-VIS-XS-1.00) 1” (CD-ADD-TOP-VIS-XS-1.00)

OTHER (CD-ADD-LOW-VIS-XS-OTHER) (3”Max) OTHER (CD-ADD-MID-VIS-XS-OTHER) (2”Max) OTHER (CD-ADD-TOP-VIS-XS-OTHER) (2”Max)

VISCO EXTRA EXTRA SOFT $138.00 VISCO EXTRA EXTRA SOFT $138.00 VISCO EXTRA EXTRA SOFT $138.00

1/2” (CD-ADD-LOW-VIS-XXS-0.50) 1/2” (CD-ADD-MID-VIS-XXS-0.50) 1/2” (CD-ADD-TOP-VIS-XXS-0.50)

1” (CD-ADD-LOW-VIS-XXS-1.00) 1” (CD-ADD-MID-VIS-XXS-1.00) 1” (CD-ADD-TOP-VIS-XXS-1.00)

OTHER (CD-ADD-LOW-VIS-XXS-OTHER) (3”Max) OTHER (CD-ADD-MID-VIS-XXS-OTHER) (2”Max) OTHER (CD-ADD-TOP-VIS-XXS-OTHER) (2”Max)

LOWER LAYER MID LAYER TOPPER LAYER

H.R. MEDIUM $0.00 H.R. MEDIUM $0.00 H.R. MEDIUM $0.00

1/4”** (CD-LOW-HRM-0.25) 1/4” (CD-MID-HRM-0.25) 1/4” (CD-TOP-HRM-0.25)

1/2” (CD-LOW-HRM-0.50) 1/2” (CD-MID-HRM-0.50) 1/2” (CD-TOP-HRM-0.50)

3/4” (CD-LOW-HRM-0.75) 3/4” (CD-MID-HRM-0.75) 3/4” (CD-TOP-HRM-0.75)

1” (CD-LOW-HRM-1.00) 1” (CD-MID-HRM-1.00) 1” (CD-TOP-HRM-1.00)

1 1/4” (CD-LOW-HRM-1.25) 1 1/4” (CD-MID-HRM-1.25) 1 1/4” (CD-TOP-HRM-1.25)

OTHER (CD-LOW-HRM-OTHER) (3”Max) OTHER (CD-MID-HRM-OTHER) (2”Max) OTHER (CD-TOP-HRM-OTHER) (2”Max)

H.R. SOFT $0.00 H.R. SOFT $0.00 H.R. SOFT $0.001/4” (CD-LOW-HRS-0.25) 1/4” (CD-MID-HRS-0.25) 1/4” (CD-TOP-HRS-0.25)

1/2” (CD-LOW-HRS-0.50) 1/2” (CD-MID-HRS-0.50) 1/2” (CD-TOP-HRS-0.50)

3/4” (CD-LOW-HRS-0.75) 3/4” (CD-MID-HRS-0.75) 3/4” (CD-TOP-HRS-0.75)

1” (CD-LOW-HRS-1.00) 1” (CD-MID-HRS-1.00) 1” (CD-TOP-HRS-1.00)

1 1/4” (CD-LOW-HRS-1.25) 1 1/4” (CD-MID-HRS-1.25) 1 1/4” (CD-TOP-HRS-1.25)

OTHER (CD-LOW-HRS-OTHER) (3”Max) OTHER (CD-MID-HRS-OTHER) (2”Max) OTHER (CD-TOP-HRS-OTHER) (2”Max)

VISCOOL™ MEDIUM $138.00 VISCOOL™ MEDIUM $138.00 VISCOOL™ MEDIUM $138.00

1/2” (CD-LOW-VIS-M-0.50) 1/2” (CD-MID-VIS-M-0.50) 1/2” (CD-TOP-VIS-M-0.50)

1” (CD-LOW-VIS-M-1.00) 1” (CD-MID-VIS-M-1.00) 1” (CD-TOP-VIS-M-1.00)

OTHER (CD-LOW-VIS-M-OTHER) (3”Max) OTHER (CD-MID-VIS-M-OTHER) (2”Max) OTHER (CD-TOP-VIS-M-OTHER) (2”Max)

VISCOOL™ SOFT $138.00 VISCOOL™ SOFT $138.00 VISCOOL™ SOFT $138.00

1/2” (CD-LOW-VIS-S-0.50) 1/2” (CD-MID-VIS-S-0.50) 1/2” (CD-TOP-VIS-S-0.50)

1” (CD-LOW-VIS-S-1.00) 1” (CD-MID-VIS-S-1.00) 1” (CD-TOP-VIS-S-1.00)

OTHER (CD-LOW-VIS-S-OTHER) (3”Max) OTHER (CD-MID-VIS-S-OTHER) (2”Max) OTHER (CD-TOP-VIS-S-OTHER) (2”Max)

VISCOOL™ EXTRA SOFT $138.00 VISCOOL™ EXTRA SOFT $138.00 VISCOOL™ EXTRA SOFT $138.00

1/2” (CD-LOW-VIS-XS-0.50) 1/2” (CD-MID-VIS-XS-0.50) 1/2” (CD-TOP-VIS-XS-0.50)

1” (CD-LOW-VIS-XS-1.00) 1” (CD-MID-VIS-XS-1.00) 1” (CD-TOP-VIS-XS-1.00)

OTHER (CD-LOW-VIS-XS-OTHER) (3”Max) OTHER (CD-MID-VIS-XS-OTHER) (2”Max) OTHER (CD-TOP-VIS-XS-OTHER) (2”Max)

VISCO EXTRA EXTRA SOFT $138.00 VISCO EXTRA EXTRA SOFT $138.00 VISCO EXTRA EXTRA SOFT $138.00

1/2” (CD-LOW-VIS-XXS-0.50) 1/2” (CD-MID-VIS-XXS-0.50) 1/2” (CD-TOP-VIS-XXS-0.50)

1” (CD-LOW-VIS-XXS-1.00) 1” (CD-MID-VIS-XXS-1.00) 1” (CD-TOP-VIS-XXS-1.00)

OTHER (CD-LOW-VIS-XXS-OTHER) (3”Max) OTHER (CD-MID-VIS-XXS-OTHER) (2”Max) OTHER (CD-TOP-VIS-XXS-OTHER) (2”Max)

1/4” CROSSLINK* (CD-FOAM-STRUCTURAL-0.25) $0.00

* Crosslink is not recommended when using a Moldable ATI (Section 19)

FOA

M R

EC

OM

ME

ND

ATI

ON

S B

Y U

SER

WE

IGH

T:

PEDIATRIC or USER <100 lbs. (45 kg) HRM HRS VIS-M VIS-S VIS-XS VIS-XXSLower Layer Minimum 1 ½” (lower

and mid layer combined)• • •

Mid Layer • • • • • •Topper Layer Minimum ¼” • • • • • •

STANDARD USER 100 to 350 lbs. (45-158 kg) HRM HRS VIS-M VIS-S VIS-XS VIS-XXSLower Layer Minimum 1 ½” (lower

and mid layer combined)• •

Mid Layer • • • •Topper Layer Minimum ¼” • • • • • •

BARIATRIC USER >350 lbs. (158 kg) HRM HRS VIS-M VIS-S VIS-XS VIS-XXSLower Layer Minimum 3” (lower

and mid layer combined)• •

Mid Layer • • •Topper Layer Minimum ½” • • • • • •

8 FOAM LAYERS

STRUCTURAL LAYER

NOTE: A minimum thickness mid layer must be selected if an ischial modification is selected in Section 9. See Section 9 for details.

”OTHER” Viscool™ and Visco layers must be in 1/2” increments.

(OPTIONAL)(OPTIONAL)(OPTIONAL)

** 1/4” lower layer is only to be used in conjunction with 1/4” structural layer.

*** Additional foam layers will be placed on top of the original layer.

FULL LENGTH RECESS

REAR QUADRANT RECESS

15 GROWTH NOTCHES

16 RAIL CUTS

13 ISCHIAL RECESSThe amount of recess must match the mid layer of foam selected in Section 8, a topper layer must also be selected with this option.

FRONTFRONT

FRONT VIEW

FRONTFRONT

Right

Left

Left

Right

14 HAMSTRING RELIEFOnly ONE option may be selected. Left or right side relief will be half the width of the seat support.

FULL WIDTH RELIEF

LEFT SIDE ADDUCTOR $0.00

RIGHT SIDE ADDUCTOR $0.00

ISCHIAL MEMORY FOAM INSERT $62.00

GEL INSERTS

LEFT SIDE RELIEF

RIGHT SIDE RELIEF

$35.00

1” D (CD-HAM-RELIEF-1)

2” D (CD-HAM-RELIEF-2)

OTHER (CD-HAM-RELIEF-OTHER)

$35.00

1” D (CD-LEFT-HAM-RELIEF-1)

2” D (CD-LEFT-HAM-RELIEF-2)

OTHER (CD-LEFT-HAM-RELIEF-OTHER)

$35.00

1” D (CD-RIGHT-HAM-RELIEF-1)

2” D (CD-RIGHT-HAM-RELIEF-2)

OTHER (CD-RIGHT-HAM-RELIEF-OTHER)

$33.331” D (CD-GROWTH-NOTCH-1)

2” D (CD-GROWTH-NOTCH-2)

3” D (CD-GROWTH-NOTCH-3)

OTHER (CD-GROWTH-NOTCH-OTHER)

1¼” wide cut will be taken from each side to allow cushion to fit between chair canes. Growth notches may affect adductors in the rear of the seat support. Tip: An Anti-Thrust Growth Kit from Section 7 can be used to adjust the seat well depth also if an anti-thrust feature is needed.

$0.00NONE (CD-ABD-NONE)

½” H (CD-ABD-HEIGHT-0.5)

1” H (CD-ABD-HEIGHT-1.0)

1½” H (CD-ABD-HEIGHT-1.5)

2” H (CD-ABD-HEIGHT-2.0)

2½” H (CD-ABD-HEIGHT-2.5)

OTHER (CD-ABD-HEIGHT-OTHER)

HEIGHTNONE (CD-RIGHT-ADD-NONE)

½” H (CD-RIGHT-ADD-0.5)

1” H (CD-RIGHT-ADD-1.0)

1½” H (CD-RIGHT-ADD-1.5)

2” H (CD-RIGHT-ADD-2.0)

2½” H (CD-RIGHT-ADD-2.5)

OTHER (CD-RIGHT-ADD-OTHER)

1” THICK SOFT MEMORY FOAM* (CD-ISCHIAL-SOFT-1.0)

1” THICK EXTRA SOFT MEMORY FOAM* (CD-ISCHIAL-XSOFT-1.0)

1” THICK EXTRA EXTRA SOFT MEMORY FOAM* (CD-ISCHIAL-XXSOFT-1.0)

½” THICK SOFT MEMORY FOAM*(CD-ISCHIAL-SOFT-0.5)

½” THICK EXTRA SOFT MEMORY FOAM*(CD-ISCHIAL-XSOFT-0.5)

½” THICK EXTRA EXTRA SOFT MEMORY FOAM*(CD-ISCHIAL-XXSOFT-0.5)

HEIGHTNONE (CD-LEFT-ADD-NONE)

½” H (CD-LEFT-ADD-0.5)

1” H (CD-LEFT-ADD-1.0)

1½” H (CD-LEFT-ADD-1.5)

2” H (CD-LEFT-ADD-2.0)

2½” H (CD-LEFT-ADD-2.5)

OTHER (CD-LEFT-ADD-OTHER)

STYLETAPERED (CD-LEFT-ADD-TAPERED)

STRAIGHT (CD-LEFT-ADD-STRAIGHT)

REAR ONLY (CD-LEFT-ADD-REAR-ONLY)

FRONT ONLY (CD-LEFT-ADD-FRONT-ONLY)

STYLETAPERED (CD-RIGHT-ADD-TAPERED)

STRAIGHT (CD-RIGHT-ADD-STRAIGHT)

REAR ONLY (CD-RIGHT-ADD-REAR-ONLY)

FRONT ONLY (CD-RIGHT-ADD-FRONT-ONLY)

$35.001” H (CD-RAIL-CUT-1.0)

1½” H (CD-RAIL-CUT-1.5)

2” H (CD-RAIL-CUT-2.0)

OTHER (CD-RAIL-CUT-OTHER)

1½” wide cut will be made along the entire depth of seat support. Rail cuts will affect the amount of cushion left along the sides of especially low-profile seat supports.

$158.00

LEFT SIDE RIGHT SIDE¼” H (CD-IR-LEFT-REAR-0.25) ¼” H (CD-IR-RIGHT-REAR-0.25)

½” H (CD-IR-LEFT-REAR-0.50) ½” H (CD-IR-RIGHT-REAR-0.50)

¾” H (CD-IR-LEFT-REAR-0.75) ¾” H (CD-IR-RIGHT-REAR-0.75)

1” H (CD-IR-LEFT-REAR-1.0) 1” H (CD-IR-RIGHT-REAR-1.0)

1¼” H (CD-IR-LEFT-REAR-1.25) 1¼” H (CD-IR-RIGHT-REAR-1.25)

OTHER OTHER(CD-IR-LEFT-REAR-OTHER) (CD-IR-RIGHT-REAR-OTHER)

$158.00

LEFT SIDE RIGHT SIDE¼” H (CD-IR-LEFT-FULL-0.25) ¼” H (CD-IR-RIGHT-FULL-0.25)

½” H (CD-IR-LEFT-FULL-0.50) ½” H (CD-IR-RIGHT-FULL-0.50)

¾” H (CD-IR-LEFT-FULL-0.75) ¾” H (CD-IR-RIGHT-FULL-0.75)

1” H (CD-IR-LEFT-FULL-1.0) 1” H (CD-IR-RIGHT-FULL-1.0)

1¼” H (CD-IR-LEFT-FULL-1.25) 1¼” H (CD-IR-RIGHT-FULL-1.25)

OTHER OTHER(CD-IR-LEFT-FULL-OTHER) (CD-IR-RIGHT-FULL-OTHER)

12 COCCYX CUT OUTCOCCYX CUT OUT (CD-COCCYX-CUT) $0.00

Cut out will be in the lower layer.

ISCHIAL GEL INSERT* (CD-ISCHIAL-GEL) $69.00

Two gel-filled compartments recessed into the mid layer foam in the seat well.

QUADRAGEL® INSERT* (CD-QUADRAGEL) $90.00

Four gel-filled compartments recessed into the mid layer foam in the seat well and through the leg troughs.

11 ABDUCTION

10 ADDUCTION

RIGHT LEFT

Select an adductor height AND style for each the left and right side.

Front or rear only will be a straight style adductor and be 1/2 the seat support depth or match an anti-thrust depth.

Only ONE insert may be selected.

Straight Adductor

Tapered Adductor

REAR ONLY Adduction Area

FRONT ONLY Adduction Area

FRONT

REAR


LEFTADDUCTOR

RIGHTADDUCTOR

REAR VIEW

H H

H

9 ISCHIAL MODIFICATION

* A mid layer of foam must be selected and, at a minimum, match the selected insert thickness.

* ½” minimum mid layer is required when this insert.

* ¾” minimum mid layer is required with this insert.

Rectangular piece of memory foam which is recessed into the mid layer foam in the seat well.

Ischial inserts are recessed into the mid layer of foam and sit beneath the topper layer.

All custom requests should be added in “NOTES” section on page 4 along with the section

number they are in reference to.

$0.00RED (CD-RED) BLUE (CD-BLUE)

PURPLE (CD-PURPLE) GREEN (CD-GREEN)

PINK (CD-PINK) REMOVE (CD-REMOVE)

Accent colors are applied via colored piping. If no color is selected, our standard silver reflective piping will be used.

$500.00SOLID SEAT PAN (CD-RSSP-N-HARD)

SOLID SEAT PAN W/ STANDARD LEG LENGTH DISPREPANCY (CD-RSSP-STND-LLD)

SOLID SEAT PAN W/ OFFSET LEG LENGTH DISPREPANCY (CD-RSSP-OFF-LLD)

MOLDABLE ATIADJUSTABLE TECHNOLOGY INSERT (CD-MOLDABLE-INSERT) $193.00

RIGID INSERT - GLUED(CD-RGD-INSERT-GLUED) $84.00

RIGID INSERT - NOT GLUED(CD-RGD-INSERT-UNGLUED) $84.00

$0.00AIR FORCE(CD-AIR-FORCE-PATCH)

MARINES (CD-MARINES-PATCH)

ARMY (CD-ARMY-PATCH)

NAVY (CD-NAVY-PATCH)

Patch is added to the cover on each side. Alters appearance only.

ZIPPERED POUCH (CD-ZIP-POUCH) $35.00

Zippered Pouch is sewn into the front of the seat support cover.

24 BODILINK® LATERAL PELVIC/ THIGH SUPPORT HARDWARE

23 LATERAL THIGH SUPPORT PADS HCPCS CODE: E0953

ZERO ELEVATION $52.00

ANTI-THRUST $52.00

LD L D

- OR -

*Length (L) refers to the actual size dimension of the support

from bottom to top edge.

22 COLOR

21 ZIPPERED POUCH

20 MILITARY BRANCH PATCH18 PLATFORM

19 INSERT

Accommodates 7/8” or 1” tubing. Two different cross bars are included to accommodate various wheelchair frame types. Fits both folding and non-folding seat rails. Lateral thigh supports can easily be attached.

Moldable ATI (Adjustable Technology Insert) enables on-site customization to the contour of the seat support surface. 1/4” Crosslink is not recommended with Moldable ATI and will not be included if a Quick Pick Shape was selected in Section 5.

Rigid Insert is 3/16” thick.

17 LEG LENGTH DISCREPENCYThe discrepancy reduces the seat depth on the specified side. Standard cut out is half the seat support width.

An Offset Leg Length Discrepancy maintains foam abductor shape if built into the seat support or removable abductor centered placement. If offset is selected, the cutout width is reduced by 1½”.

STANDARD DISCREPANCY DEPTH

OFFSET DISCREPANCY DEPTH

SIZE

(BL-LPTSP1Z-3L4D-LH) 3” L X 4” D (BL-LPTSP1Z-3L4D-RH)










$103.00

LEFT SIDE RIGHT SIDE½” D (CD-LLD-DEPTH-L-0.5) ½” D (CD-LLD-DEPTH-R-0.5)

1” D (CD-LLD-DEPTH-L-1.0) 1” D (CD-LLD-DEPTH-R-1.0)

1½” D (CD-LLD-DEPTH-L-1.5) 1½” D (CD-LLD-DEPTH-R-1.5)

2” D (CD-LLD-DEPTH-L-2.0) 2” D (CD-LLD-DEPTH-R-2.0)

OTHER OTHER(CD-LLD-DEPTH-L-OTHER) (CD-LLD-DEPTH-R-OTHER)

$103.00

LEFT SIDE RIGHT SIDE½” D (CD-LLD-O-DEPTH-L-0.5) ½” D (CD-LLD-O-DEPTH-R-0.5)

1” D (CD-LLD-O-DEPTH-L-1.0) 1” D (CD-LLD-O-DEPTH-R-1.0)

1½” D (CD-LLD-O-DEPTH-L-1.5) 1½” D (CD-LLD-O-DEPTH-R-1.5)

2” D (CD-LLD-O-DEPTH-L-2.0) 2” D (CD-LLD-O-DEPTH-R-2.0)

OTHER OTHER(CD-LLD-O-DEPTH-L-OTHER) (CD-LLD-O-DEPTH-R-OTHER)

SIZE(BL-LPTSP1A-3L4D-LH) 3” L X 4” D (BL-LPTSP1A-3L4D-RH)

(BL-LPTSP1A-3L5D-LH) 3” L X 5” D (BL-LPTSP1A-3L5D-RH)









END CUSTOM INCEPTION SEAT SUPPORT OPTIONS

LEFT EXTRALEFT

RIGHT EXTRARIGHT

ZERO ELEVATION ANTI-THRUST

You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section A for pad sizes and shapes. In section B, select a cover for each pad selected in section A.

A. BASIC PAD SIZE & SHAPE

COMFORT-TEK™ ($0.00/EA.) LPTS-P1-COMFORT LPTS-P1-COMFORT

STRETCH-AIR™ ($0.00/EA.) LPTS-P1-STRETCH LPTS-P1-STRETCH

GLIDEWEAR® ($13.00/EA.) LPTS-P1-GLIDE LPTS-P1-GLIDE

B. BASIC PAD COVER

LEFT EXTRALEFT

RIGHT EXTRARIGHT

LEFT EXTRALEFT

RIGHT EXTRARIGHT

A. TT HARDWARE, SLOT MOUNT

You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section A, B, -or- C. TT long extention arms (section D) will only work with TT style hardware and GT hardware links (section D) will only work with GT style hardware.

SIZE

(BL-LPTS-TT1FXSL1-LH) SMALL (BL-LPTS-TT1FXSL1-RH)

(BL-LPTS-TT1FXSL2-LH) MEDIUM (BL-LPTS-TT1FXSL2-RH)

(BL-LPTS-TT1FXSL3-LH) LARGE (BL-LPTS-TT1FXSL3-RH)

- OR -

LEFT EXTRALEFT

RIGHT EXTRARIGHT

SIZE

(BL-LPTS-TT1RMSL1-LH) SMALL (BL-LPTS-TT1RMSL1-RH)

(BL-LPTS-TT1RMSL2-LH) MEDIUM (BL-LPTS-TT1RMSL2-RH)

(BL-LPTS-TT1RMSL3-LH) LARGE (BL-LPTS-TT1RMSL3-RH)

LEFT EXTRALEFT

RIGHT EXTRARIGHT

FIXED

REMOVABLE E1028 $248.00

$141.00

B. TT HARDWARE, POWER MOUNT

SIZE

(BL-LPTS-TT1FXPWL1-LH) SMALL (BL-LPTS-TT1FXPWL1-RH)

(BL-LPTS-TT1FXPWL2-LH) MEDIUM (BL-LPTS-TT1FXPWL2-RH)

(BL-LPTS-TT1FXPWL3-LH) LARGE (BL-LPTS-TT1FXPWL3-RH)

- OR -

LEFT EXTRALEFT

RIGHT EXTRARIGHT

SIZE

(BL-LPTS-TT1RMPWL1-LH) SMALL (BL-LPTS-TT1RMPWL1-RH)

(BL-LPTS-TT1RMPWL2-LH) MEDIUM (BL-LPTS-TT1RMPWL2-RH)

(BL-LPTS-TT1RMPWL3-LH) LARGE (BL-LPTS-TT1RMPWL3-RH)

LEFT EXTRALEFT

RIGHT EXTRARIGHT

FIXED

REMOVABLE E1028 $285.00

$185.00

TT HARDWARE, POWER MOUNT OPTION

QUANTUM (ADD $0.00) (LPTS-TT1-PW1)

PERMOBIL (ADD $0.00) (LPTS-TT1-PW2)

QUICKIE (ADD $0.00) (LPTS-TT1-PW3)

ROVI (ADD $0.00) (LPTS-TT1-PW4)

AVID REHAB (ADD $0.00) (LPTS-TT1-PW5)

NOTE: If choosing the Power Mount Hardware, choose the appropriate power mount type to the right.


NOTES

SUBMIT BY EMAIL


BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE CONTINUED

C. GT HARDWARE, (ONLY SLOT MOUNT)

SIZE

(BL-LPTS-GT2FXS-LH) FIXED (BL-LPTS-GT2FXS-RH)

- OR -

LEFT EXTRALEFT

RIGHT EXTRARIGHT

SIZE

(BL-LPTS-GT2RMS-LH) REMOVABLEE1028

(BL-LPTS-GT2RMS-RH)

LEFT EXTRALEFT

RIGHT EXTRARIGHT

$226.00

$103.00

D. ADDITIONAL OPTIONS

(BL-LPTS-TT1LARM4) (BL-LPTS-TT1LARM4)

- OR -

LEFT EXTRALEFT

RIGHT EXTRARIGHT

(BL-LPTS-GT2LINK) (BL-LPTS-GT2LINK)

(BL-LPTS-GT2LINK) (BL-LPTS-GT2LINK)

LEFT EXTRALEFT

RIGHT EXTRARIGHT

$37.00/LINK

$37.00/ARM

*2 additional 1.25” links allowed per hardware ordered.

END CUSTOM INCEPTION LATERAL/PELVIC THIGH OPTIONS

company name/acct #: custom inception seat...

Documents