Quickie Mach 2 FSS NET ORDER FORM/PRICE ... - Sunrise Medical

Quickie Mach 2 FSS NET ORDER FORM/PRICE LIST (SIN F-1)ORDERING INFORMATION PHONE: (800) 333-4000, FAX: (800) 300-7502, WEBSITE: www.sunrisemedical.comV797P-3821KAccount No: ___________________________________________________________________________________Drop Ship/Ship To: ___________________________________________________________Date: ________________________________________________________________________Name: ______________________________________________________________________P.O. #: ________________________________________________________________________Address: ____________________________________________________________________Buyer: _________________________________________________________________City: _________________________________________________________State:__________________________Marked For: _________________________________________________________________________Zip Code:_____________________________Phone Number:_________________________QUICKIE Mach 2EIM2, Effective July 2009ACCOUNT INFORMATIONFrame Width (Continued)CONSUMER INFORMATION: 048W7 16" NCAGE:__________________________________ 048W8 17" NCWEIGHT:__________________________________ 048W9 18" NCHEIGHT:__________________________________ 048W10 19" NCDISABILITY LEVEL/TYPE:__________________________________ 048W11 20" NCTYPE AND HEIGHT OF CUSHION TO BE USED: Frame Length_____________________________________________________ 048FL15 Standard NCPLEASE EXPLAIN ANY IMPAIRMENT OF ARM 048FL3 Short NCOR HAND FUNCTION________________________________________ Adjustable Sling Depth____________________________________________________________ 048SD5 12" NC_______________________________________________________________048SD6 13" NC048SD7 14" NCSpeed 048SD8 15" NC048SE3 7 Speed $1,416.44 048SD9 16" NCFRAMESSeat Height048HT19 Standard NCDIMENSIONS FROM DRAWING 048HT20 Tall $36.70Dimensions must be complete for proper fit. (See page 2)Hand Crank HeightA. Top of Shoulder to Center of Palm: " 048HH2 Standard NCB. Top of Shoulder to Seat: " 048HH1 Short NCC. Lower Leg Length: " CrankD. Upper Leg Length: " 048HY8 Easy Power Quad Handle $22.02E. Hip Width (Side to Side): " 048HY4 Horizontal Handle $22.02048HY5 Vertical Handle NCFRAME COLOR 048HY6 Vertical Handle Small NC048C2 Black NC Handle Position048C10 Black Opal NC 048HP2 Handle Position Crank NC048C1 Blue NC 048HP1 Handle Position Row NC048C38 Blue Opal NCSEATING048C12 Blue Velvet NC Cushion048C36 Candy Blue NC 048CU1 2" Seat Cushion $46.48048C35 Candy Red NC Back Type048C39 Candy Turquoise NC 048BT1 Folding Backrest $29.36048C6 Forest Green NC 048BT3 Non Folding Backrest NC048C4 Midnight Purple NC Back Height048C37 Orange NC 048B40 21" NC048C5 Pearl Pink NC 048B37 18" NC048C40 Razzleberry NC 048B34 15" NC048C11 Toxic Green NCFOOTREST048C8 Yellow NC Adjustable Extension Tube048E4 Standard NCCUSTOM COLORS 048E1 Short NC048C41 Berry Vibrations $144.33 Footrest048C20 Graphite $144.33 048F3 Adult Angle Adj footplate NC048C42 Stars and Stripes NC Footrest Accessories048C43 Mossy Oak Camouflage $144.33 048A110 Toe Loop NCWoodland Camouflage $144.33 FOOTNOTES:Desert Camouflage $144.331 Seat width should be the same as the rider’s present wheel chair width.Digital Woodland Camouflage $144.33Digital Desert Camouflage $144.33Digital Camouflage $144.33Frame Width 1048W4 13" NC048W5 14" NC048W6 15" NCPROPER 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 @ 2009, Sunrise Medical. Quickie Mach 2 Page 1 of 2 931208 Rev. Q. VA - 7-09