Quickie Freestyle M11 Order Form - Sunrise Medical

Quickie Freestyle M11EIPW8, Effective July 16, 2005ORDERING INFORMATION PHONE: (800) 333-4000, FAX: (800) 300-7502, WEBSITE: www.sunrisemedical.comACCOUNT INFORMATIONAccount No: ___________________________________________________________________________________Drop Ship/Ship To: ________________________________________________________________Date: ________________________________________________________________________Name: ___________________________________________________________________________P.O. #: ________________________________________________________________________Address: _________________________________________________________________________Buyer: _________________________________________________________________ City: _________________________________________________________State:__________________________Marked For: _________________________________________________________________________Zip Code:_____________________________Phone Number:_________________________135PC1 K0011 Freestyle M11 w/ Standard Options $5,245.00 High Back Comfort Seat 4 Std300 lb 5.5 mph power wheelchair Upholstery ColorEither High Back Comfort Seat 135UC8 Grey Vinyl NCor High Back Comfort Seat w/ Solid Pan 135UC9 Grey Cloth NCCenter Mount FootrestStandard Comfort Seats SizesVSI 4-Button Integral Controls 135SI1 16" x 16" NC135PC3 K0011* Freestyle M11 Base Only & Std Electronics $5,145.00 135SI5 16" x 18" NCShroud Color 135SI6 18" x 16" NCQuick-Change Shrouds Std 135SI2 18" x 18" NCIncluded at No Charge: Candy Red, Blue, Black & Champagne 135SI3 20" x 20" 6 $625.00Drive Wheel 135SI4 22" x 20" 6 $625.00135DW1 10" Alum Rim w/Pneumatic Tire NC Comfort Seat with Seat Pan 7135DW2 K0093 10" Alum. Rim & Solid Insert $220.00 16" Wide x 16" Deep Solid Seat Pan NC135W7 16" Wide NCJoystick 135FD19 16" Deep Solid Seat Pan NC135J23 Integral VSI 4-Button (70A) 5 Std 18" Wide x 18" Deep Solid Seat Pan135J24 Integral VSI 6-Button (70A) 5 $200.00 135W9 18" Wide NC135J5 E2320 Qtronix Remote $825.00 135FD21 18" Deep Solid Seat Pan NC135J4 E2320 Qtronix Remote with 1/8" jacks 1 $985.00 20" Wide x 20" Deep Solid Seat Pan $625.00Joystick Mount 135W18 20" Wide $300.00135JM1 Fixed Mount NC 135FD23 20" Deep Solid Seat Pan $325.00135JM2 E1028 Swing Away Mount $235.00 Front Seat Height (Measured to top of seat pan)135JM3 E1028 Center Mount Swing Away 2 $235.00 135HT12 17" (Only available with seat pan) NCHand Mount 135HT14 18"(Only available with seat pan) NC135HM2 Left NC 135HT17 19" NC135HM1 Right NC 135HT22 20" NCHeight Adjustable Mount 135HT23 21" NC135HI01 Fixed Mount (Std) NC 135HT24 22" NC135HI02 Height Adjustable Mount 3 $95.00 135HT25 23" NCJoystick HandleArmrest (pr)135JH3 Stick Handle NC 135AA5 Flip Back (w/12" arm pad) NC135JH1 E2323 Ball Handle $75.00 135AA6 E0973 Flip Back Hght Adjst. (w/14" arm pad) $230.00135JH2 E2323 Foam Ball Handle $75.00 Armpad (pr)135JH4 E2323 T-Handle $75.00 135AM20 Contour Armpad NCBATTERIESFootrestBatteries 135F59 Solid Flip-Up Footrest Std135A46 E2365 U1 Gel Cell (Pair) w/ Straps $230.00 135F119 Swing Away Hanger & Footrest $175.00135A150 40 Ahr AGM (Pair) w/ Straps $290.00 135F120 E0990 Manual Elev. Legrest & Footrest $300.00Battery Charger* K0011 when supplied with seat and necessary components135BJ6 4A Charger (On-Board) NC FOOTNOTES:135BJ5 4A Dual Mode (Off-Board) $310.001 Two single switches req’d to run both the on/off and mode select functions.Battery StrapsFREESTYLE M11ELECTRONICS135BK6 Battery Straps w/insert (U1 & 40Ahr) NC2 Not available with Integral Joystick.3 Only Available with Fixed Rehab Frame.4 No Power Seat Options with High Back Comfort Seat.5 VSI controller is a 50A with a 20A boost.6 Should be billed for width 20" or greater and depth 20" or greater.7 Only Available in grey vinylHIGH BACK COMFORT SEATING 4PROPER USE OF HCPCS CODES DOES NOT ENSURE COVERAGE OR PAYMENT. FOR COVERAGE INFORMATION , VERIFY THE APPROPRIATE PAYER’S COVERAGE POLICY.Specifications are subject to change without notice. Copyright @ 2005, Sunrise Medical. (7.05) Quickie Freestyle M11 - Page 1 of 4 931170 Rev. D

Quickie Freestyle M11, June 2005SEATING- Traditional Rehab Seating System135ST8 Traditional Fixed Rehab Frame $450.00135SL2 Seat Sling Parapak Std 135AA44 Dual Post Flip Back NC135SL5 Seat Pan Aluminum (NC on C.G. Tilt) $110.00 135AA51 E0973 Dual Post Flip Back Height Adjustable $245.00135SL6 Omit Seat Sling -$15.00 135AA8 E0973 Single Post Height Adjustable 5 $230.00135CU1 2" Cushion $95.00 135AA14 Omit Armrest and Mounts NCSeat WidthArmpad136S5 14" NC 135AE01 Desk Length Waterfall (10") NC136S6 15" NC 135AE02 Full Length Waterfall (14") NC136S7 16" NC 135AE03 Desk Length Standard (10") $15.00136S8 17" NC 135AE04 Full Length Standard (14") $15.00136S9 18" NCFOOTREST136S10 19" NC Hanger (pr) (Center Mount Footrest Always Included)136S11 20" (NC with Power CG Tilt) $325.00 135H2 70 o Swing Away 6 (A,B,C) $160.00136S27 22"1(Not available with Power CG Tilt) $325.00 135H37 90 o Swing Away 6 (B,C) $160.00136S28 24"1(Not available with CG Tilt) $465.00 135H16 E0990 Manual Elevating SA 6 (A,B,D) $270.00Seat Depth-AdjustableExtension Tube135SD7 14" NC 135E1 Short (13" - 15.5") NC135SD8 15" NC 135E2 Medium (15.5" - 18") NC135SD9 16" NC 135E5 Long (18" - 20") NC135SD10 17" NC Footplate (pr)135SD11 18" NC 135F1 Composite w/Heel Loop NC135SD12 19" NC135SD13 20" (NC with Power CG Tilt) $450.00Front Seat Height 2135SH13 15.5" NC 135F3 Adult Angle Adjustable w/Heel Loop (pr) $210.00135SH15 16.5" NC K0040 Angle Adjustable Footplate $165.00135SH17 17.5" NC E0951 Heel Loop $45.00135SH20 18.5" NC135SH23 19.5" NC 135F9 Kids Angle Adjustable w/Leg Strap (pr) $195.00BACKREST7K0040 Angle Adjustable Footplate $165.00135BT3 Non-Folding Backrest NC K0038 Leg Strap $30.00135BT1 Folding Backrest $110.00Upholstery 135F5 Aluminum $30.00135BU1 Back Upholstery (Select Height Below) NCD3135BU26 Jay Solid Back (NC w/Power CG Tilt) $400.00(Select Height Below) 135F6 Omit Foot Plate -$15.00135BU14 Omit Back Upholstery -$15.00 Footrest Accessories135BU17 Omit Jay Solid Backrest on Tilt -$15.00 135A110 E0952 Toe Loop (pr)$45.00Back Post Type 135A54 K0038 Extra Leg Strap $30.00135BP1 Straight Back Post NC135BP3 8 o Bend Back Post4$25.00 FOOTNOTES:Back Height (Seat Frame w/Upholstery Only)1 Only available with solid seat pan.135B4 Low (15.5") $70.002 Add 2" to front seat height when CG Tilt system is selected.135B8 Medium (17.5") NC3 Decreases seat depth by 1"135B13 Tall (19.5") $70.00 4 Not Available with Jay solid seat back.Jay Solid Backrest Height (Fixed Seat Frame Only) 3135B36 16" NC135B37 17" NC135B38 18" NC135B39 19" NC135B40 20" NC135B41 21" NC135B42 22" NC135B43 23" NC135B44 24" NCABCARMREST (Ht. Adj. Armrest NC on Power C.G. Tilt)5 Not available with CG Tilt in 14" to 16" depths.6 No charge with CG tilt.7 Not available with 90 o hangers.8 Only available with adult angle adjustable footplate.8Specifications are subject to change without notice. Copyright @ 2005, Sunrise Medical. (7.05) Quickie Freestyle M11 - Page 2 of 4 931170 Rev. D.

Quickie Freestyle M11, June 2005SEATING- Traditional Rehab Seating System (Continued)Headrest (Included on Specialty Controls)Packages Include:-Universal Specialty Control Module (USCM)-Model/Reset Switch135HE1 Headrest 8" x 4.5" $450.00 -All Necessary Mounting HardwareE0955 Curved Headrest 8" x 4.5" $225.00 -Input DeviceE1028 Removable Mount $225.00 USCM Hand Mount135HE2 Headrest 9" x 4.5" $450.00 135UH2 Left Side NCE0955 Curved Headrest 9" x 4.5" $225.00 135UH1 Right Side NCE1028 Removable Mount $225.00 PackagesLateral Thoracic Support 135ID26 Sip-N-Puff Package 6,10 $2,795.00Pad Style E2325 Sip-N-Puff Kit $1,870.00135KE1 Lateral Pads Curved $450.00 E0995 Headrest $265.00E0956 Lateral Pad Curved (pr) $225.00 E1028 Headrest removable Mount $210.00E1028 Swing Away Mount (pr) $225.00 E2326 Sip-N-Puff Breath Tube $450.00135KE2 Lateral Pads Straight $440.00E0956 Lateral Pad Straight (pr) $215.00 135ID31 ASL Head Array Package - Adult 6,10 $5,795.00E1028 Swing Away Mount (pr) $225.00 E2330 ASL Proximity Head Array $5,585.00Pad Size E1028 Head Array Removable Mounting Hdwr $210.00135KD1 Lateral Support 3" x 6" (pr) NC135KD2 Lateral Support 4" x 5" (pr) NC 135ID30 ASL Head Array Package - Pediatric 6,10 $5,795.00135KD3 Lateral Support 4" x 6" (pr) NC E2330 ASL Proximity Head Array $5,585.00POWER SEAT OPTION 1E1028 Head Array Removable Mounting Hdwr $210.00135PT1 E1002 CG Tilt 50° (Fixed Frame Only) $4,350.00135LB3 0 to 175 lbs NC 135ID13 Switch It Head Array Package - Adult 10 $4,390.00135LB4 176 to 300 lbs NC E2330 Switch It Proximity Head Array $4,180.00Power CG Tilt Electronics Options E1028 Head Array Removable Mounting Hdwr $210.00135TC1 Dual Toggle Activation & Control Std135TC5 Omit Dual Toggle 2 -$20.00 135ID14 Switch It Head Array Package - Pediatric 10 $4,390.00135TC6 E2310 Thru Drive Control 3 $650.00 E2330 Switch It Proximity Head Array $4,180.00135TC9 E2310 Thru Drive Control & Attendant Toggle $775.00 E1028 Head Array Removable Mounting Hdwr $210.00(Choose Mount Below)4135TD02 Left Back Post Mount 5 NC 135ID28 HMC Mini Joystick Chin/Lip Control Pckg 6 $4,595.00135TD01 Right Back Post Mount 5 NC E2320 HMC Mini Joystick $4,120.00135TD03 Velcro Mount to Attendant Control 5 NC E0995 Headrest $265.00SPECIALTY INPUT INDIVIDUAL COMPONENTSE1028 Headrest Removable Mount $210.00Specialty Input InterfacePOSITIONING OPTIONS (For solid backs only)Qtronix-USCM (Interface & Display Module) 135ID32 HMC Mini Joystick w/Midline Gatlin Pckg 6 $4,595.00135AI2 E2320 USCM Left, Swing Away Mount $1,250.00 E2320 $4,385.00135AI1 E2320 USCM Right, Swing Away Mount $1,250.00 E1028 Swing Away Mount $210.00135AI4 E2320 USCM & Omit Mount $1,200.00Specialty Input Device 135ID33 Penta Switch Package 6 $1,195.00Requires USCME2322 (No Mount for Penta)135ID6 CA-5 Interface Box $150.00135ID9 Mini Proportional Joystick 6 $780.00 135ID12 Proportional Head Control Package 6,10 $3,795.00135ID10 Penta Switch $200.00 E2327 Proportional Head Control $3,585.00Single Switch E1028 Removable Mount $210.00135SW1 Buddy Button Switch $55.00135SW2 Disc Switch $120.00 FOOTNOTES135SW10 Egg Switch-Black $95.00135SW4 Micro Light Switch $75.00135SW6 Ribbon Switch $45.00135SW9 Wobble Switch $200.00135SW11 Switch Mount Bracket 7,8 $195.00Specialty Input Accessories135SA01 Drive Input Device Switch Box 9 $750.00135SA04 E2320Remote Joystick w/Jacks - Swing Away Mount $985.00(For Use with Drive Input Switch Box)135SA03 E2320 Remote Joystick w/Jacks - Fixed Mount $965.00(For Use with Drive Input Switch Box)1 Traditional Rehab Seat only2 Single switch required to operate one power option except ELR.3 Requires either 6 button VSI or Remote joystick.4 Attendent Toggle requires remote joystick or USCM option.5 For attendant toggle switch.6 Single switch required for mode/stop switch.7 Mounts on 7/8" tubing.8 Not available with wobble switch.9 Allows use of a remote and a specialty input device alternatively.10 Solid Backrest must be selected.SPECIALTY INPUT PACKAGESSpecifications are subject to change without notice. Copyright @ 2005, Sunrise Medical. (7.05) Quickie Freestyle M11 - Page 3 of 4 931170 Rev. D

Quickie Freestyle M11, June 2005Backpack1135A1 Black Utility $55.00 Chair Weight: 139.5 lbs. Without batteries and footplate135A2 Black/Charcoal Kids $50.00 User Weight: Maximum 300 lbs.Seat Pouch Width: 22.5"135A8 Black $45.00 Length: 32" (without Footplate)Holders (Not available with the PF Seating or any CG tilt)38.5" (with Footplate)135A153 K0102 Cane & Crutch Holder $125.00 Range: Up to 20 miles.135A151 K0104 O2 Tank Holder $150.00 Range: Up to 20 miles.135A152 Walker Holder $125.00 Casters: 6"135A154 SA Front Basket & Mount 2 $190.00Miscellaneous135A82 Caddy 3 $45.00135RB1 Readi-Align Caster Set of 2 $75.00Auxiliary Control135A42 E2351 Auxiliary Control Module4$795.00135A44 4-1/8" Mono Plug Cable $60.00135A43 9 Pin Output Cable $60.00Attendant ControlACCESSORIES135A450 E2331 Attendant Drive Control6Positioning Belt (Seat Frames Only)5$795.00135A155 E0978 Auto Style Buckle $50.00135A12 E0978 Belt 2" Aircraft Buckle $85.00135A13 E0978 Belt 2" Aircraft Buckle Padded $115.00Wheelchair Tray Table 7135A31 E0950 Medium Tuffak (15"-17") $225.00135A32 E0950 Large Tuffak (18"-20") $225.00135A33 E0950 X-Large Tuffak (21"-22") $225.00Programmer135PR1 Qtronix Programmer Pad $525.00QUICKIE FREESTYLE M11 SPECIFICATIONSTOTAL CHAIR PRICE $FOOTNOTES:1 Mounts only to Rehab Seat Frames2 Basket can not be used with swing-away or elevating hangers.3 Requires swing-away footrests4 Only compatible with the USCM5 Mount Available for Seat Frames Only. Not available with Integral Controller. OperatesDrive only, no power seat options.6 Positioning Belt is standard with High-back comfort seat7 Standard armpads required for proper fit.Sunrise Medical7477 E. Dry Creek PkwyLongmont, CO 80503(800) 333-4000Specifications are subject to change without notice. Copyright @ 2005, Sunrise Medical. (7.05) Quickie Freestyle M11 - Page 4 of 4 931170 Rev. D.