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  • Three column pricing on order/quote:

    PO#:______________________________

    Dealer Code:______________________________

    *Dealer Name:______________________________

    * State/Zip:______________________________

    Order ID:______________________________

    Address:______________________________

    * Phone#:______________________________

    * Weight:_______________________________

    *Height:_______________________________

    A) Top of Shoulders:_______________________________

    B) Chest Depth:_______________________________

    C) Chest Width:_______________________________

    D) Seat Depth:_______________________________

    E) Top of Head:_______________________________

    F) Elbow to Hand:_______________________________

    G) Seat Pan to Elbow:_______________________________

    H) Hip Width:_______________________________

    *I) Knee to Foot:_______________________________

    Permobil Inc.300 Duke Dr.

    Lebanon, TN 37090Tel: (800) 736-0925Fax: (800) 231-3256

    www.permobil.com

    *City:______________________________

    Diagnosis:______________________________

    Permobil recommends that the client is evaluated by a certified rehab specialist.

    Dealer Information

    Client Information

    Client Measurements

    Funding Source:______________________________

    Prices effective October 01, 2018

    Client Age:______________________________

    *ATP:______________________________

    * First Name:______________________________

    * Indicates a Required Field

    * Last Name:______________________________

    Email Address:______________________________

    Display HCPCS Codes on order/quote:

    Please send order/quote to fax#: (800) 231-3256 Email to: [email protected]

    M1 - SPO

  • M1 - SPOChair Model and Colors

    CHOOSE BASE:Part Number Description Price HCPCS Code

    I108006-99-0 M1 Base - SPO 7,895.00 K0856Price Includes: MWD M1 Power Base Set Up For One Power Seat Function, FlexLink Suspension System, 7" Flat Free Casters, Tie-Down Hardware for Strap Systems and Charger. Max Speed = 5mph, Weight Capacity = 300lbs, STFH = 16".

    CHOOSE DRIVE TIRES:Part Number Description Price HCPCS Code

    I107974-99-0 Flat Free Tire 3"W x 14"T - Black No Charge I107975-99-0 Pneumatic Tire 3"W x 14"T - Black No Charge

    OPTIONAL DRIVE TIRES:Part Number Description Price HCPCS Code

    I107976-99-0 Pneumatic/Snow Tire 3"W x 14"T Black 470.00Snow tires are designed for use in cold weather conditions. The nylon compound in these tires remains flexible at low temperatures, but wears more easily. Therefore, the snow tires (sold as wheel assemblies) are not recommended for year-long use and must be ordered along with standard drive wheels. Does not include caster wheels.

    CHOOSE SHROUD COLOR:Part Number Description Price HCPCS Code

    SHROUD COLOR OPTIONS: I107967-99-0 M1 Color Kit - Sunburst Orange No Charge I107968-99-0 M1 Color Kit - Galactic Green No Charge I107969-99-0 M1 Color Kit - Midnight Black No Charge I107970-99-0 M1 Color Kit - Ocean Blue No Charge I107971-99-0 M1 Color Kit - Power Pink No Charge I107973-99-0 M1 Color Kit - Radiant Red No Charge I108205-99-0 M1 Color Kit - Mossy Oak Break-Up Country 204.00 I108206-99-0 M1 Color Kit - Carbon Fiber 204.00 I108207-99-0 M1 Color Kit - CDG Poly 204.00 I108387-99-0 M1 Color Kit - American Liberty 204.00 I108386-99-0 M1 Color Kit - Midnight Patriot 204.00

    Base OptionsCHOOSE ONE OF THE FOLLOWING:

    Part Number Description Price HCPCS CodePLEASE NOTE:

    Additional parts are required to change the seat to floor height in the field.

    I108021-99-0 Seat to Floor Height - 16" No Charge I108022-99-0 Seat to Floor Height - 17" No Charge I108023-99-0 Seat to Floor Height - 18" No Charge

    MUST CHOOSE BATTERIES:Part Number Description Price HCPCS Code

    BATTERY OPTIONS: I107032-99-0 Batteries, Grp 34 (60Ah) Sealed Gel, x2, Installed 960.00 E2359

    OPTIONAL ITEMS:Part Number Description Price HCPCS Code

    I107998-99-0 Enhanced Steering Perform Unit (ESP), R-net 1,519.00 K0108 I108337-99-0 Light Kit for M1 1,233.00

    Only available with R-net electronics.

    I108105-99-0 Compact Laptop Ventilator Tray - M1 1,607.00Accommodates Pulmonetic Systems / CareFusion LTV Series and similar sized Laptop Ventilators. The tray is 13"T, adjustable Width between 8" - 13", and adjustable Depth between2" - 6.5". Custom Option.

    Page 2 of 13Rev 2018-2 10/01/2018

  • M1 - SPOBase Options

    OPTIONAL ITEMS:Part Number Description Price HCPCS Code

    I10787 Battery Tray for Laptop Ventilator Tray 269.00Measures 11 3/8" W x 6 1/2" H x 1 5/8" D. Accomodates Pulmonetic Systems Lithium-Ion Battery Pack, CareFusion SprintPack Battery System, or Richardson PowerTech Vent Power Center. Custom Option.

    I10788 O2 Holder for Laptop Ventilator Tray 341.00Mounts to Left or Right Side of Laptop Vent Tray. O2 Holder is 7" Tall. Width infinitely adjustable 3.5" - 7". Depth infinitely adjustable 3.75" - 5". Custom Option.

    I101161-99-0 PP1A Programmer - VR2 567.00 ID51113 Programming Key for R-net - Permobil Version 526.00

    Joystick OptionsCHOOSE JOYSTICK TYPE:

    Part Number Description Price HCPCS Code I103613-99-0 VR2 Advanced Joystick No Charge

    Non expandable joystick capable of controlling up to 2 power functions through the joystick.

    I11237 VR2 90 Amp Upgrade 206.00Select this option to upgrade the power module on a tilt only chair to allow future addition of power elevating legrests.

    I108319-99-0 Permobil Joystick Module 1,082.00Designed exclusively for Permobil, this R-net color joystick features: control of up to 4 Bluetooth devices, Infrared control, programmable buttons and a programmable switch jack; all in a compact, durable Aluminum housing.

    I108289-99-0 R-net LED Remote Joystick - No Display No ChargeThis Joystick does NOT have a Display Screen and does NOT contain mono jacks. Limited to five profiles with this Joystick Module.

    CHOOSE JOYSTICK HANDLE TYPE:Part Number Description Price HCPCS Code

    I10045 Cone Shaped Joystick Knob - Standard No Charge I100960-99-0 Chin Cup For Joystick Knob 127.00 E2324 I100961-99-0 "T" Handle For Joystick Knob 179.00 E2323 I100962-99-0 "Large Ball" For Joystick Knob 127.00 E2323 I100963-99-0 "Softball" For Joystick Knob 167.00 E2323 I100964-99-0 "Mushroom" For Joystick Knob 167.00 E2323 I100965-99-0 "Stick" For Joystick Knob 167.00 E2323 I105442-99-0 1.75" Black Foam Ball For Joystick Knob 127.00 E2323 I105846-99-0 Bodypoint J/S Handle 3" U-Shaped w/ Flex-Shaft 167.00 E2323 I105847-99-0 Bodypoint J/S Handle 4" U-Shaped w/ Flex-Shaft 167.00 E2323 I105848-99-0 Bodypoint J/S Handle Dome Shaped, Rubber 167.00 E2323

    CHOOSE JOYSTICK MOUNT:Part Number Description Price HCPCS Code

    I11216 Joystick Mount Right - Fixed No Charge I11217 Joystick Mount Left - Fixed No Charge I108037-99-0 Slimline Retractable Joystick Mount - Right 503.00 E1028 I108038-99-0 Slimline Retractable Joystick Mount - Left 503.00 E1028 I11232 Adjustable Height Panel Bracket 273.00 E1028

    Provides 1.77" of vertical adjustment below the armrest and 25° of angle adjustment. Compatible with all Permobil joystick mounts except for the M1 Fixed Joystick Mount.

    I108311-99-0 Mount Standard JS on Back Cane as Attendant Control 344.00OPTIONAL ITEMS:

    Part Number Description Price HCPCS Code I11238 Expandable Controller - R-net 699.00 E2377

    This item is required with upgrade to R-net electronics or when ordering an Alternative Drive Control.

    Page 3 of 13Rev 2018-2 10/01/2018

  • M1 - SPOJoystick Options

    OPTIONAL ITEMS:Part Number Description Price HCPCS Code

    I10513 Harness for Expandable Controller 620.00 E2313Must be ordered with any Expandable Controller.

    I108312-99-0 Attendant Control R-Net for 1" Diameter Tube 1,372.00 E2331Seating System

    CHOOSE ONE OF THE FOLLOWING:Part Number Description Price HCPCS Code

    I107978-99-0 50° Power Tilt - M1 6,995.00 E1002Backrest angle can be manually adjusted up to 110°. A 1/2 speed limitation is applied when thetilt angle is > or = to 20°.

    I108185-99-0 EZ Fold Backrest 220.00This feature allows the tubular backrest frame to be easily folded forward to reduce the transport height of an unoccupied wheelchair.

    Seating System OptionsCHOOSE SEAT FUNCTION CONTROL TYPE:

    Part Number Description Price HCPCS Code I11239 Single Seat Function Control - No Charge No Charge I11240 Single Seat Function Control 1,932.00 E2310

    For operation of 1 power seat function through the wheelchair electronics via the drive controls.

    I11280 Multiple Seat Function Control 3,657.00 E2311For operation of two or more power seat functions through the wheelchair electronics via the drive control.

    Backrest OptionsCHOOSE TUBULAR BACKREST FRAME:

    Part Number Description Price HCPCS CodePLEASE NOTE:

    Tubular Backrest features 1" diameter back canes. The Tubular Backrest Frame and the Backrest Width Must match the Seat Width. The Backrest cane height is 20" from the seat pan to the bend of the canes.

    I107985-99-0 Tubular Backrest Frame - 14"W No Charge I107986-99-0 Tubular Backrest Frame - 16"W No Charge I107987-99-0 Tubular Backrest Frame - 18"W No Charge I107988-99-0 Tubular Backrest Frame - 20"W No Charge I107989-99-0 Tubular Backrest Frame - 22"W No Charge

    CURVED, SOLID BACKREST OPTIONS:Part Number Description Price HCPCS Code

    PLEASE NOTE: The Curved, Solid Backrests will come with a leatherette backrest cushion. The backrest shell will be set 3" above the seat pan.

    I108086-99-0 Curved, Solid Backrest - 14"W x 16"T No Charge I108085-99-0 Curved, Solid Backrest - 16"W x 20"T No Charge I108087-99-0 Curved, Solid Backrest - 18"W x 20"T No Charge I108088-99-0 Curved, Solid Backrest - 20"W x 20"T No Charge I108089-99-0 Curved, Solid Backrest - 22"W x 20"T No Charge I11231 Omit Backrest No Charge

    ROHO AGILITY BACKREST OPTIONS:Part Number Description Price HCPCS Code

    ROHO AGILITY NOTE: The ROHO AGILITY Back Systems are available in widths of 14", 16", 18" and 20" and shell heights of 16", 18" and 20". Includes backrest shell, cushion, air inserts, UT rail for lateral adjustment of the headrest and quick release attachment hardware. The backrest shell will be set 3" above the seat frame.

    Page 4 of 13Rev 2018-2 10/01/2018

  • M1 - SPOBackrest Options

    ROHO AGILITY BACKREST OPTIONS:Part Number Description Price HCPCS Code

    I11219 ROHO AGILITY Mid Contour Back System 665.00 E2620Shell Width (14", 16", 18", 20"W):______ Shell Height (16", 18", 20"H):______

    I11220 ROHO AGILITY Max Contour Back System 779.00 E2620Shell Width (14", 16", 18", 20"W):______ Shell Height (16", 18", 20"H):______

    Seat SizingCHOOSE SEAT WIDTH:

    Part Number Description Price HCPCS CodePLEASE NOTE:

    The Seat Width is available in 2" increments from 14"-22" and is not adjustable without additional parts. Please select Seat Width below. The seat width must match the backrest width.

    I107980-99-0 Set Seat Width at 14" No Charge I107979-99-0 Set Seat Width at 16" No Charge I107982-99-0 Set Seat Width at 18" No Charge I107981-99-0 Set Seat Width at 20" No Charge I107984-99-0 Set Seat Width at 22" No Charge

    CHOOSE SEAT DEPTH:Part Number Description Price HCPCS Code

    PLEASE NOTE: The Seat Depth is adjustable from 14"-22" in 1" increments without additional parts. Please select the Seat Depth below.

    I107991-99-0 Set Seat Depth at 14" No ChargeUser weight cannot exceed 165lbs.

    I107992-99-0 Set Seat Depth at 15" No Charge I107993-99-0 Set Seat Depth at 16" No Charge I107994-99-0 Set Seat Depth at 17" No Charge I107995-99-0 Set Seat Depth at 18" No Charge I107996-99-0 Set Seat Depth at 19" No Charge I107997-99-0 Set Seat Depth at 20" No Charge I108028-99-0 Set Seat Depth at 21" No Charge I108029-99-0 Set Seat Depth at 22" No Charge

    CHOOSE SEAT CUSHION:Part Number Description Price HCPCS Code

    PLEASE NOTE: ROHO seat cushions may not be available to fit all width & depth seat size combinations.

    I11222 ROHO AirLITE Cushion < 22"W 188.00 E2605Registered in PDAC under ROHO model numbers AL1414HD - AL2018HD.

    I11166 ROHO QUADTRO SELECT HIGH PROFILE < 22"W 586.00 E2624Registered in PDAC under ROHO model numbers QS98C - QS1114C.

    I11167 ROHO QUADTRO SELECT HIGH PROFILE > or = 22"W 628.00 E2625Registered in PDAC under ROHO model numbers QS128C - QS1413C.

    I11223 ROHO Hybrid Elite SR Cushion < 22"W 530.00 E2622Registered in PDAC under ROHO model numbers 1RHE1414C-SR - 1RHE2020C-SR.

    I11224 ROHO Hybrid Elite SR Cushion - 22"W 552.00 E2623Registered in PDAC under ROHO model numbers 1RHE2218C-SR - 1RHE2220C-SR.

    I107505-99-0 ROHO Smart Check Device 254.00 K0108Sensing device that allows users to setup and maintain proper inflation pressure in ROHO Sensor Ready cushions. Only available when ordered with a ROHO Sensor Ready cushion.

    I105118-99-0 Omit Seat Cushion No ChargeArmrest Options

    Page 5 of 13Rev 2018-2 10/01/2018

  • M1 - SPOArmrest Options

    CHOOSE ONE OF THE FOLLOWING:Part Number Description Price HCPCS Code

    PLEASE NOTE: The Low Mount Armrest Assembly can be adjusted from 7"-12" from the seat pan. The High Mount Armrest Assembly can be adjusted from 10"-14" from the seat pan. Please select the High or Low Mount Armrest Assembly and Armrest Height below.

    I11225 Locking Flip Back Height Adj Armrests - High No Charge I11226 Locking Flip Back Height Adj Armrests - Low No Charge

    SET ARMREST HEIGHT AT:______CHOOSE ARMREST PAD RIGHT:

    Part Number Description Price HCPCS Code I105100-99-0 4"x10" Corpus Armrest Pad Right - Leatherette No Charge I105104-99-0 4"x13" Corpus Armrest Pad Right - Leatherette No Charge I107212-99-0 4"x10" Corpus Armrest Pad Right - Black Fabric No Charge I106047-99-0 4"x13" Corpus Armrest Pad Right - Black Fabric No Charge I107591-99-0 4"x10" Corpus Arm w/ Permobil Gel Pad - Right 175.00 I107593-99-0 4"x13" Corpus Arm w/ Permobil Gel Pad - Right 180.00 I108091-99-0 2"x10" Narrow Armrest Pad - Right No Charge I108092-99-0 2"x14" Narrow Armrest Pad - Right No Charge

    CHOOSE ARMREST PAD LEFT:Part Number Description Price HCPCS Code

    I105098-99-0 4"x10" Corpus Armrest Pad Left - Leatherette No Charge I105102-99-0 4"x13" Corpus Armrest Pad Left - Leatherette No Charge I107213-99-0 4"x10" Corpus Armrest Pad Left - Black Fabric No Charge I106046-99-0 4"x13" Corpus Armrest Pad Left - Black Fabric No Charge I107590-99-0 4"x10" Corpus Arm w/ Permobil Gel Pad - Left 175.00 I107592-99-0 4"x13" Corpus Arm w/ Permobil Gel Pad - Left 180.00 I108090-99-0 2"x10" Narrow Armrest Pad - Left No Charge I108093-99-0 2"x14" Narrow Armrest Pad - Left No Charge

    OPTIONAL ITEMS:Part Number Description Price HCPCS Code

    I107339-99-0 Armrest Pouch - Right 244.00 I107338-99-0 Armrest Pouch - Left 244.00 I107840-99-0 UT Armrest Side Support - Right Outer 352.00

    Includes 2"T x 6.5"W tapered pad.

    I107863-99-0 UT Armrest Side Support - Left Outer 352.00Includes 2"T x 6.5"W tapered pad.

    I107864-99-0 UT Armrest Side Support - Right Inner 352.00Includes 2"T x 6.5"W tapered pad. May require an increase to the width between the armrests to ensure armrests will flip-up.

    I107865-99-0 UT Armrest Side Support - Left Inner 352.00Includes 2"T x 6.5"W tapered pad. May require an increase to the width between the armrests to ensure armrests will flip-up.

    I107839-99-0 UT Elbow Support - Right 174.00 K0108Must also select PN I10881.

    I107838-99-0 UT Elbow Support - Left 174.00 K0108Must also select PN I10882.

    I10881 Adjustable Elbow Support Hardware - Right 256.00 I10882 Adjustable Elbow Support Hardware - Left 256.00

    Legrest OptionsCENTER MOUNT LEGREST OPTIONS:

    Part Number Description Price HCPCS CodeCenter Mount Legrest Options:

    Page 6 of 13Rev 2018-2 10/01/2018

  • M1 - SPOLegrest Options

    CENTER MOUNT LEGREST OPTIONS:Part Number Description Price HCPCS Code

    I108015-99-0 Manual Elevating Legrest - Center Mount No Charge I108016-99-0 Power Elevating Legrest - 140° - Center Mount 2,995.00 E1012

    Center Mount Footplate Options: I108212-99-0 2pc Narrow Footplates - 8.5"D x 5.5"W, Short Ext No Charge

    Footplate height range, 7-12.5"

    I108094-99-0 2pc Narrow Footplates - 8.5"D x 5.5"W, Long Ext No ChargeFootplate height range, 11-16"

    I108156-99-0 2pc Wide Footplates - 9"D x 7.5"W 269.00Footplate height range, 11-16" Risk of caster interference possible. Legrest angle must be adjusted to ensure footplates clear casters while driving.

    Center Mount Calf Support Options: I108203-99-0 UT Calf Support Kit (B) w Mesh Cover & Adj Hardware No Charge

    3.5"W x 4.5"T Pad.

    I108200-99-0 UT Calf Support Kit (J) w Mesh Cover & Adj Hardware No Charge5"W x 6.5"T Pad.

    I108204-99-0 UT Calf Support Kit (A) w Mesh Cover & Adj Hardware No Charge5.5"W x 6"T Pad.

    I108201-99-0 UT Calf Support Kit (H) w Mesh Cover & Adj Hardware 384.007"W x 7"T Curved Pad.

    I108202-99-0 UT Calf Support Kit (D) w Mesh Cover & Adj Hardware 384.008"W x 8"T Pad.

    SWING AWAY LEGREST OPTIONS:Part Number Description Price HCPCS Code

    Swing Away Legrest Options: I108158-99-0 Swing Away Legrest Assembly - Standard, Pair 320.00

    Angle Adjustable from 65-80°. Footplate height range is from 13-16".

    I108318-99-0 Swing Away Legrest Assembly - Short, Pair 320.00Angle Adjustable from 65-80°. Footplate height range is from 9-12". Calf Supports are not available with this configuration.

    Swing Away Footplate Options: I108153-99-0 Small, Multi-Axis Adj. Footplates w/ Heel Loops 240.00 K0040,E0951

    Footplate size is 5.5"W x 6"L. Only available with 14" seat widths.

    I108154-99-0 Medium, Multi-Axis Adj. Footplates w/ Heel Loops 240.00 K0040,E0951Footplate size is 6.5"W x 8"L. Only available with 16 - 18" seat widths.

    I108155-99-0 Large, Multi-Axis Adj. Footplates w/ Heel Loops 240.00 K0040,E0951Footplate size is 8.5"W x 10"L. Only available with 20-22" seat widths. Not available with 14" seat depth. The legrest angle will be set to ensure the footplates clear the casters.

    Swing Away Calf Support Options: I108287-99-0 SA Calf Support Kit (B) w Mesh Cover No Charge

    Pad size is 3.5"W x 4.5"T.

    I108284-99-0 SA Calf Support Kit (J) w Mesh Cover No ChargePad size is 5"W x 6.5"T.

    I108288-99-0 SA Calf Support Kit (A) w Mesh Cover No ChargePad size is 5.5"W x 6"T.

    I108285-99-0 SA Calf Support Kit (H) w/ Mesh Cover 384.00Pad size is 7"W x 7"T, curved pads.The footplates will not flip up with these calf supports.

    CHOOSE ONE OF THE FOLLOWING:Part Number Description Price HCPCS Code

    Page 7 of 13Rev 2018-2 10/01/2018

  • M1 - SPOLegrest Options

    CHOOSE ONE OF THE FOLLOWING:Part Number Description Price HCPCS Code

    SET FOOTPLATE HEIGHT AT:______This is measured from the SEAT PAN to the top of the FOOTPLATE, when the legrest assembly is at 90°. Do NOT include cushion thickness in your measurement. In one inch increments, please indicate desired footplate height. NOTE: The footplate height must be set at least 2" less than the seat height. Higher footplate heights may be possible depending upon configuration. Height may need to be reduced for shipping.

    AccessoriesMUST CHOOSE POSITIONING BELT:

    Part Number Description Price HCPCS Code I100518-99-0 Positioning Belt No Charge I104520-99-0 Bodypoint Padded Hip Belt - Medium 153.00 I104516-99-0 Bodypoint Padded Hip Belt - Large 204.00

    HEADREST OPTIONS:Part Number Description Price HCPCS Code

    I107470-99-0 Permobil 7"W Headrest w/ Link Hardware 397.00 E0955Must also select I107480-99-0 or I107481-99-0.

    I107469-99-0 Permobil 10"W Headrest w/ Link Hardware 397.00 E0955Must also select I107480-99-0 or I107481-99-0.

    I107468-99-0 Permobil 14"W Headrest w/ Link Hardware 397.00 E0955Must also select I107480-99-0 or I107481-99-0.

    I107480-99-0 Adj/Removable Headrest Link Hardware - Standard 273.00 E1028 I107481-99-0 Adj/Removable Headrest Link Hardware - Extended 294.00 E1028

    Includes an additional 3" link to extend headrest pad range.

    I11305 Swing Away Egg Switch Assembly 586.00 E1028Mount on Upper Left:____ Mount on Upper Right:_____

    I11306 Swing Away Microlight Assembly 668.00 E1028Mount on Upper Left:____ Mount on Upper Right:_____

    I11307 Swing Away Facial Pad Assembly 4"L x 2"T 475.00 E1028Mount on Upper Left:____ Mount on Upper Right:_____

    I11308 Swing Away Facial Pad Assembly 6"L x 2"T 475.00 E1028Mount on Upper Left:____ Mount on Upper Right:_____

    OPTIONAL ITEMS:Part Number Description Price HCPCS Code

    I103070-99-0 UT Amp. Support Pad (H) w/ Mesh Cover - (1 Each) 165.00 E10207"W x 7"T Curved Pad. Must also select PN I10553.

    I103071-99-0 UT Amp. Support Pad (D) w/ Mesh Cover - (1 Each) 165.00 E10208"W x 8"T Flat Pad. Must also select PN I10553.

    I10553 Adj Removable - Amp Support Hardware (1 Each) 280.00Please indicate if you would like the amputation support mounted on the right or left side of the seat frame: Mount Amp Suppt on Left: ____ Mount Amp Suppt on Right: ____

    I106104-99-0 UT Hip Suppt (B) w/ Mesh Cover - High (Pair) 288.00 E09564.5"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

    I106103-99-0 UT Hip Suppt (A) w/ Mesh Cover - High (Pair) 288.00 E09566"W x 5.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

    I103094-99-0 UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair) 288.00 E09566.5"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

    I103095-99-0 UT Thigh/Hip Suppt (C) w/ Mesh Cover - High (Pair) 288.00 E09568"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

    I102977-99-0 UT Thigh/Hip Suppt (G) w/ Mesh Cover - High (Pair) 288.00 E095612"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.

    I10550 Adj Removable - Thigh Support Hardware (Pair) 551.00 E1028

    Page 8 of 13Rev 2018-2 10/01/2018

  • M1 - SPOAccessories

    OPTIONAL ITEMS:Part Number Description Price HCPCS Code

    I105260-99-0 Transfer Handles, Corpus Seat 503.00 K0108 I106210-99-0 RAM Self-Leveling Cup Holder 85.00 I106806-99-0 RAM X-Grip Phone Holder 85.00 I107100-99-0 RAM X-Grip 10" Tablet Holder w/Swing Away Mount 427.00

    Compatible with most 10" screen tablets with or without a protective case. Includes adjustable swing away mount (I103476-99-0). Customization may be required if ordered with an Omni.

    I105805-99-0 Medical Necessities Bag Hooks 101.00 K0108Please Note: Recline is limited to 165° or less (depending on backrest height) when ordered with 23" or 24" tall Ergo backrest. Custom required if ordered with a ROHO AGILITY backrest.

    I102059-99-0 Medical Necessities Bag 293.00Includes hardware to attach bag to backrest. Please Note: Recline is limited to 165° or less (depending on backrest height) when ordering with a 23" or 24" tall Ergo backrest. Custom required if ordered with a ROHO AGILITY backrest.

    I108336-99-0 Repositioning Handles for 1" Diameter Tube 447.00 I10843 Small Angle Adjustable Tray 309.00 E0950

    Must also select PN I10556. Mount on Left: _____ Mount on Right: _____

    I10556 Adj Removable - Tray Hardware (1 Each) 280.00 I108231-99-0 Permobil Adjustable Tray - 11"W 260.00 E0950 I108230-99-0 Permobil Adjustable Tray - 13"W 260.00 E0950 I108228-99-0 Permobil Adjustable Tray - 15"W 260.00 E0950 I108227-99-0 Permobil Adjustable Tray - 17"W 260.00 E0950 I108229-99-0 Permobil Adjustable Tray - 19"W 260.00 E0950 I108232-99-0 Permobil Tray Hardware Right Side Adjustable 190.00 I108233-99-0 Permobil Tray Hardware Left Side Adjustable 190.00 I108107-99-0 Crutch Holder for 1" Diameter Tube 275.00 E2207 I108106-99-0 O2 Holder for 1" Diameter Tube 275.00

    Alternative Drive SystemsALTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:

    Part Number Description Price HCPCS Code I10751 Mini-Joystick for Omni - (9-pin connector) 3,314.00 E2312

    Operating Force = 0.5 oz (13 g) Neutral to Full Deflection = 0.2" (5mm)

    I103893-99-0 Compact Joystick for Omni - (9-pin connector) 1,621.00 E2373Operating Force = 7.8 oz (220 g) Neutral to Full Deflection = 1.1" (28mm) Joystick includes two 1/8" mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball Knob.

    I103894-99-0 Compact Joystick LITE for Omni - (9-pin connector) 1,834.00 E2373Operating Force = 1.8 oz (50 g) Neutral to Full Deflection = 0.7" (17mm) Joystick includes two 1/8" mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball Knob.

    ALT PROPORTIONAL JOYSTICK MOUNTING HARDWARE:Part Number Description Price HCPCS Code

    NOTE: Please see the PERMOfix Mounting Solutions, within the Alt Drive Accessories section, for additional mounting options.

    I104690-99-0 Alt JS Swing Away Mount Kit - Armrest 284.00 E1028Mount in front of Left Arm: _____ Mount in front of Right Arm: _____

    I107135-99-0 Alt JS / Omni Combo Swing Away Mount Kit - Armrest 537.00 E1028Used to mount Omni and Alternative Proportional Joystick to the same armrest. Includes Swing Away Omni/Tablet Mount, with a longer mounting rod, two PERMOfix modules, one 3" rod and one 4" rod. Mount in front of Left Arm: _____ Mount in front of Right Arm:_____

    I10752 Haims Harness for Chin Control Mount, Large 629.00 E1028For neck width up to 7½".

    Page 9 of 13Rev 2018-2 10/01/2018

  • M1 - SPOAlternative Drive Systems

    ALT PROPORTIONAL JOYSTICK MOUNTING HARDWARE:Part Number Description Price HCPCS Code

    I10753 Haims Harness for Chin Control Mount, Small 629.00 E1028For neck width up to 5½".

    ALT PROPORTIONAL JOYSTICK ACCESSORIES:Part Number Description Price HCPCS Code

    I104904-99-0 Dual Switches for Compact Joystick - Fixed Mount 263.00Includes two pushbutton switches mounted on rigid arms. Switches can be used for Mode & On/Off. Switch operation force = 4.5oz (130 g) Mount at front of Joystick: _____ Mount at rear of Joystick: _____ Mount at left of Joystick: _____ Mount at right of Joystick: _____

    I104641-99-0 Dual Switches for Compact Joystick -Gooseneck Mount 474.00Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches are positioned on Left and Right sides of Compact Joystick. Switches can be used for Mode & On/Off. Switch operation force = 4.5oz (130 g)

    SIP & PUFF SYSTEMS:Part Number Description Price HCPCS Code

    I10573 Sip & Puff System for Omni 1,773.00 E2325,E2326Requires Omni Control Module. Includes breath tube kit.

    I10574 Sip & Puff System with Fiber Optic Opti-Stop 2,360.00 E2325,E2326Requires Omni Control Module. Includes breath tube kit.

    I106807-99-0 Sip & Puff Kit for Total Control Head Array 914.00 E2325For use with Total Control Head Array. Requires Omni Control Module. Includes breath tube kit.

    I10762 Adjustable Mounting Hrdw - Sip & Puff 284.00Required when selecting PN I10573, I10574 or I106807-99-0.

    Total Control Head ArrayCONFIGURE HEAD ARRAY:

    Part Number Description Price HCPCS Code I106805-99-0 Permobil Head Array - 3-Switch System 4,893.00 E2330

    Features an occipital pad sensor and two stainless steel arms configured with proximity sensors. The arms are mounted to the upper attachment points on the head array. Longer arms are also included to extend the sensor adjustment range. ESP recommended. Choose Omni Control Module separately.

    I11072 Program Head Array as a 5-Switch System No ChargeSelect additional arms/sensors below and indicate the intended use of each sensor in the Notes & Comments section. Choose Omni Control Module separately.

    CHOOSE OCCIPITAL PAD SIZE (REQUIRED): I105920-99-0 Small Occipital Pad for Head Array - 4.25"W x 3"H No Charge I105921-99-0 Large Occipital Pad for Head Array - 6"W x 4"H No Charge

    . CHOOSE OCCIPITAL MOUNT (REQUIRED):

    I10847 Fixed Mount for Head Array Occipital Pad No Charge I105936-99-0 Adj. Swivel Mount for Head Array Occipital Pad 439.00 K0108

    Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms.

    CHOOSE HEAD ARRAY MOUNT HARDWARE (REQUIRED): I105927-99-0 Stealth TWB480 Backrest Mounting Hdwr with Links 293.00 E1028

    Please select the length of the vertical stem below: Standard length (10"): _____ Short length (6"): _____

    I105941-99-0 Stealth TWB480 Backrest Mnt Hdwr with Flipback 473.00 E1028 I105925-99-0 Stealth HMO475 MultiAxis Backrest Mounting Hdwr 260.00 E1028 I106319-99-0 Stealth TWB480 Backrest Mnt Hdwr w SubOcptl Mount 508.00 E1028 I106282-99-0 Stealth 600 SubOccipital Pad - 8.5" W x 2.75" H 104.00 K0108

    Must select when PN I106319-99-0 is ordered.

    Page 10 of 13Rev 2018-2 10/01/2018

  • M1 - SPOTotal Control Head Array

    CONFIGURE HEAD ARRAY:Part Number Description Price HCPCS Code

    SELECT ADDITIONAL LEFT ARM PACKAGE (OPTIONAL): I10976 Add Left Lateral Arm w Proximity Sensor 630.00

    Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______

    I10977 Add Left Lateral Arm w Egg Switch 515.00Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______

    I10978 Add Left Lateral Arm w Pad (No Sensor or Switch) 420.00Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______

    SELECT ADDITIONAL RIGHT ARM PACKAGE (OPTIONAL): I10979 Add Right Lateral Arm w Proximity Sensor 630.00

    Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______

    I10980 Add Right Lateral Arm w Egg Switch 515.00Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______

    I10981 Add Right Lateral Arm w Pad (No Sensor or Switch) 420.00Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______

    Alt Drive Systems SetupCHOOSE OMNI (REQUIRED):

    Part Number Description Price HCPCS Code I108397-99-0 OMNI2 Control Module for R-net - M1 1,887.00

    Two-section design features 3.5" VGA high resolution display, USB charger port, built in IR control and integrated Bluetooth technology for control of up to 4 Bluetooth devices. Must also select mounting hardware below. Please specify which type of alternative drive input device you will be using. Input Device:______________________________ Not available until after November 30th 2018.

    I103476-99-0 Adjustable Swing-Away Hardware - Omni/Tablet 284.00Mount in front of Left Arm: _____ Mount in front of Right Arm: _____

    Alt Drive AccessoriesPERMOFIX MOUNTING SOLUTIONS:

    Part Number Description Price HCPCS Code I106655-99-0 PERMOfix UniTrack Fixed Mount Kit 286.00

    Includes two base joints, two 4" rods and one 8" rod.

    I106656-99-0 PERMOfix UniTrack Removable Mount Kit 502.00Includes quick release mount and thigh support hardware, two base joints and three different length rods.

    I106657-99-0 PERMOfix UniTrack Swing Away Mount Kit 719.00Includes PERMOfix Swing Away module, two base joints, one 2" rod and one 4" rod.

    I105907-99-0 Proximity Sensor + Swivel Assembly 363.00 E1028Only available with the Total Control Head Array. Swivel assembly allows sensor to be mounted with PERMOfix or directly to lateral arm of Total Control Head Array. Since Proximity Sensors require power, they CANNOT be used as On/Off switches.

    I105919-99-0 Egg Switch + Swivel Mount Assembly 245.00Swivel assembly allows switch to be mounted with PERMOfix or directly to lateral arm of Total Control Head Array.

    I105912-99-0 Solid Oval Pad + Swivel Assembly 148.00Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total Control Head Array.

    I106675-99-0 Oval Plate + Swivel Assembly - No Switch 130.00Blank plate provides mounting option for Micro Lite, Buddy Button or other switch options. Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total Control Head Array.

    Page 11 of 13Rev 2018-2 10/01/2018

  • M1 - SPOAlt Drive Accessories

    OPTIONAL ITEMS:Part Number Description Price HCPCS Code

    I101769-99-0 Microlight Switch Qty:____ 198.00 I101767-99-0 Buddy Button Qty:____ 167.00 I106293-99-0 Egg Switch Black Qty: _____ 167.00 I101771-99-0 Mini Cup Switch Qty:____ 167.00 I107500-99-0 Proximity Switch Qty:____ 662.00 I107495-99-0 Mini Joyswitch 5 Switch OC for Omni - (9-pin) 718.00 I107498-99-0 Touch Contact with CR2032 Battery Qty:____ 408.00 I10772 Dome Switch, Backrest Mnt w Gooseneck Qty: _____ 524.00

    Mount on Left: _____ Mount on Right: _____ Mounts at top of backrest shell. Custom charge may be applied if ordering with short backrest heights Kit Includes: One PERMOfix joint with Flat Plate, two PERMOfix joints with 45° swivel adjustment, one 6" rod, one 8" rod and one 9" gooseneck switch with 50" cable and mounting clamp.

    I10846 Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty:____ 775.00 K0108Mount on Left: _____ Mount on Right: _____ w 90° Swing-Away Function. Mounts at top of back. Custom charge applies if ordered with short back. Kit Includes: One PERMOfix joint with Flat Plate, one PERMOfix joint with 45° swivel adjustment, two 6" rods, one 90° Swing-Away joint, one 9" gooseneck switch w 50" cable and mounting clamp.

    I105935-99-0 3.5mm Ext. Cable for Sensor/Switch, 0.3m Long 33.00 I105931-99-0 3.5mm Ext. Cable for Sensor/Switch, 1m Long 36.00 I105932-99-0 3.5mm Ext. Cable for Sensor/Switch, 2m Long 42.00 I105933-99-0 3.5mm Ext. Cable for Sensor/Switch, 3m Long 46.00 I105934-99-0 3.5mm Y-splitter Cable for Sensor/Switch 36.00

    Allows two Proximity Sensors/Mechanical Switches to connect to the same direction jack.

    Page 12 of 13Rev 2018-2 10/01/2018

  • Additional Order Instructions (for Permobil):

    Notes & Comments (not for Permobil):

    Chair Order Policy:You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms at 1-800-736-0925. The order cannot be processed without the following: -A client name or code, the client’s measurements, the client’s weight -The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil, Inc. is not responsible for configuration or size discrepancies resulting from customer errors on the order form. -Order confirmations will be provided by Permobil summarizing the items selected. Please review this carefully. -Once the order is shipped, any changes are subject to the returns policy and may be prohibited.

    Order Acknowledgement:

    I, _________________________, am an agent of the medical equipment provider named on this order form and I have the authority to contract for the purchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete and accurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returns policy and may carry additional charges.

    Signed:

    Printed Name:

    Title:

    Date:NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if ordered with the wheelchair. Any parts ordered for service or future alterations will carry different pricing and warranty. The HCPCS codes provided are not intended to be billing or legal advice, rather our interpretation of the code definitions. Use of the codes does not ensure coverage or payment for the item. For coverage information, verify the policy of the appropriate payer.

    Page 13 of 13Rev 2018-2 10/01/2018

  • M1 - Comfort Company® Seating Order Form

    BACK SUPPORTS(INCLUDES STRETCH-AIR™ FABRIC AND COMPASS® 4 QUICK RELEASE (2 POINT) HARDWARE)

    Acta-Back® Length (inches)

    14-20W, 16-18L E2613

    16-20W, 20L $636.00 E2613

    22W, 18L $658.00 E2614

    22W, 20L $721.00 E2614

    Page 1 of 2

    10”W x 5”L $255.00 E0955

    Price USD HCPCS Code

    PREMIUM PAD: (INCLUDES SOFT PAD AND STRETCH-AIR™ FABRIC). Must also select mounting hardware below.

    BODILINK™ HEAD SUPPORT (Only Available with Acta-Back® or Acta-Relief™)

    12”W x 5”L $255.00 E0955

    Price USD HCPCS Code

    PT HARDWARE: (INCLUDES MOUNTING BLOCK AND 7” STEM)

    Acta-Relief™ Length (inches)

    14-20W, 16-20L E2615

    All back supports available in listed sizes only.

    PT MID 8 (Acta-Back) $267.00 E1028

    Size

    Width (inches)

    Price USD

    $560.00

    HCPCS Code

    14W 16W 18W 20W 22W

    20L

    18L

    16L

    14W 16W 18W 20W

    20L

    18L

    16L

    Size Width (inches)

    Price USD

    $825.00

    HCPCS Code

    3”L x 5.5”D (Acta-Back) $260.00 E0956

    4”L x 6.5”D (Acta-Back) $260.00 E0956

    Pair: Price USD HCPCS Code

    PREMIUM PAD: (INCLUDES SUPPORTIVE ORIENTATION, MOLDABLE, AND STRETCH-AIR™ FABRIC). Must also select mounting hardware below.

    BODILINK™ LATERAL TRUNK SUPPORTS (Only Available with Acta-Back® or Acta-Relief™)

    Swing-Away $595.00 E1028

    Pair: Price USD HCPCS Code

    GT2 HARDWARE:

    $355.00 E1028

    I11317

    I11318

    I11319

    I11320

    I11321

    I108446-99-0

    I108447-99-0

    PT MID 8 (Acta-Relief)

    I11322

    I11323

    I108454-99-0

    I108456-99-0

    I108455-99-0

    I108457-99-0

    I11324

    3"L x 5.5"D (Acta-Relief)

    4"L x 6.5"D (Acta-Relief)

    Comfort Company® items require dealer installation.

  • Page 2 of 2

    CUSHION/SEAT SUPPORTSCHOOSE MODEL AND SIZE BELOW: (INCLUDES COMFORT-TEK FABRIC)

    14-20W $405.00 E2607

    22W $455.00 E2608

    M2 Anti-Thrust Width (inches) Depth (inches)

    BODILINK™ LATERAL PELVIC/THIGH SUPPORTS

    3.5”L x 8”D $190.00 E0953

    3.5”L x 12”D $190.00 E0953

    Price USD HCPCS Code

    TT HARDWARE:

    $580.00 E1028

    PREMIUM PAD: (INCLUDES FOAM INSERT AND STRETCH-AIR™ FABRIC). Must also select mounting hardware below.

    Pair: Price USD HCPCS Code

    Medium (Cushion Thickness 3.0”- 5.5”)

    14W 16W 18W 20W 22W22D20D18D16D14D

    Size Price USD HCPCS Code

    I11325

    I11326

    I108458-99-0

    I108459-99-0

    I11327

    Pair:

    US-M1 SPOOfficial CC Seating M1 Order Form_100418

    Three column pricing on orderquote: OffDisplay HCPCS Codes on orderquote: OffOrder ID: ATP: Dealer Code: Dealer Name: Address: City: StateZip: Phone: PO: Email Address: First Name: Last Name: Diagnosis: Funding Source: Client Age: Weight: Height: A Top of Shoulders: B Chest Depth: C Chest Width: D Seat Depth: E Top of Head: F Elbow to Hand: G Seat Pan to Elbow: H Hip Width: I Knee to Foot: I107974990: OffI107975990: OffI107976990: OffI107967990: OffI107968990: OffI107969990: OffI107970990: OffI107971990: OffI107973990: OffI108205990: OffI108206990: OffI108207990: OffI108387990: OffI108386990: OffI108021990: OffI108022990: OffI108023990: OffI107998990: OffI108337990: OffI108105990: OffI10787: OffI10788: OffI101161990: OffID51113: OffI103613990: OffI11237: OffI108319990: OffI108289990: OffI10045: OffI100960990: OffI100961990: OffI100962990: OffI100963990: OffI100964990: OffI100965990: OffI105442990: OffI105846990: OffI105847990: OffI105848990: OffI11216: OffI11217: OffI108037990: OffI108038990: OffI11232: OffI108311990: OffI11238: OffI10513: OffI108312990: OffI108185990: OffI11239: OffI11240: OffI11280: OffI107985990: OffI107986990: OffI107987990: OffI107988990: OffI107989990: OffI108086990: OffI108085990: OffI108087990: OffI108088990: OffI108089990: OffI11231: OffI11219: OffI11220: OffShell Width 14 16 18 20W: Shell Height 16 18 20H: Shell Width 14 16 18 20W_2: Shell Height 16 18 20H_2: I107980990: OffI107979990: OffI107982990: OffI107981990: OffI107984990: OffI107991990: OffI107992990: OffI107993990: OffI107994990: OffI107995990: OffI107996990: OffI107997990: OffI108028990: OffI108029990: OffI11222: OffI11166: OffI11167: OffI11223: OffI11224: OffI107505990: OffI105118990: OffI11225: OffI11226: OffSET ARMREST HEIGHT AT: I105100990: OffI105104990: OffI107212990: OffI106047990: OffI107591990: OffI107593990: OffI108091990: OffI108092990: OffI105098990: OffI105102990: OffI107213990: OffI106046990: OffI107590990: OffI107592990: OffI108090990: OffI108093990: OffI107339990: OffI107338990: OffI107840990: OffI107863990: OffI107864990: OffI107865990: OffI107839990: OffI107838990: OffI10881: OffI10882: OffI108015990: OffI108016990: OffI108212990: OffI108094990: OffI108156990: OffI108203990: OffI108200990: OffI108204990: OffI108201990: OffI108202990: OffI108158990: OffI108318990: OffI108153990: OffI108154990: OffI108155990: OffI108287990: OffI108284990: OffI108288990: OffI108285990: OffSET FOOTPLATE HEIGHT AT: I100518990: OffI104520990: OffI104516990: OffI107470990: OffI107469990: OffI107468990: OffI107480990: OffI107481990: OffI11305: OffI11306: OffI11307: OffI11308: OffMount on Upper Left: Mount on Upper Right: Mount on Upper Left_2: Mount on Upper Right_2: Mount on Upper Left_3: Mount on Upper Right_3: Mount on Upper Left_4: Mount on Upper Right_4: I103070990: OffI103071990: OffI10553: OffI106104990: OffI106103990: OffI103094990: OffI103095990: OffI102977990: OffI10550: OffMount Amp Suppt on Left: Mount Amp Suppt on Right: I105260990: OffI106210990: OffI106806990: OffI107100990: OffI105805990: OffI102059990: OffI108336990: OffI10843: OffI10556: OffI108231990: OffI108230990: OffI108228990: OffI108227990: OffI108229990: OffI108232990: OffI108233990: OffI108107990: OffI108106990: OffMount on Left: Mount on Right: I10751: OffI103893990: OffI103894990: OffI104690990: OffI107135990: OffI10752: OffMount in front of Right Arm: Mount in front of Left Arm: Mount in front of Left Arm_2: Mount in front of Right Arm_2: I10753: OffI104904990: OffI104641990: OffMount at front of Joystick: Mount at rear of Joystick: Mount at left of Joystick: Mount at right of Joystick: I10573: OffI10574: OffI106807990: OffI10762: OffI106805990: OffI11072: OffI105920990: OffI105921990: OffI10847: OffI105936990: OffI105927990: OffI105941990: OffI105925990: OffI106319990: OffI106282990: OffStandard length 10: Short length 6: I10976: OffI10977: OffI10978: OffI10979: OffI10980: OffI10981: OffShort 55 10: Long 55 14: Short 55 10_2: Long 55 14_2: Short 55 10_3: Long 55 14_3: Short 55 10_4: Long 55 14_4: Short 55 10_5: Long 55 14_5: Short 55 10_6: Long 55 14_6: I108397990: OffI103476990: Offyou will be using Input Device: Mount in front of Right Arm_3: Mount in front of Left Arm_3: I106655990: OffI106656990: OffI106657990: OffI105907990: OffI105919990: OffI105912990: OffI106675990: OffI101769990: OffI101767990: OffI106293990: OffI101771990: OffI107500990: OffI107495990: OffI107498990: OffI10772: OffI10846: OffI105935990: OffI105931990: OffI105932990: OffI105933990: OffI105934990: OffMicrolight Switch Qty: Buddy Button Qty: Egg Switch Black Qty: Mini Cup Switch Qty: Proximity Switch Qty: Touch Contact with CR2032 Battery Qty: Dome Switch Backrest Mnt w Gooseneck Qty: Mount on Left_2: Mount on Right_2: Dome Switch Backrest Swg Awy Mnt w Gsneck Qty: Mount on Left_3: Mount on Right_3: Additional Order Instructions for Permobil: Notes Comments not for Permobil: I: Signed: Printed Name: Title: Date: Width inches: Length inches: I11317: OffI11318: OffI11319: OffI11320: OffWidth inches_2: Length inches_2: I11321: OffI108446990: OffI108447990: OffI11322: OffI11323: OffI108454990: OffI108456990: OffI11324: Off3L x 55D ActaBack: Off4L x 65D ActaBack: OffWidth inches_3: Depth inches: I11325: OffI11326: OffI108458990: OffI108459990: OffI11327: Off