ACTA-EMBRACE ATI ORDER FORM - Permobil CA€¦ · ACTA-EMBRACE™ ATI ORDER FORM Patient Reference:...
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$691.00 $691.00 $753.00 $753.00 SIZE & STYLE 1 ACTA-EMBRACE ® ATI ORDER FORM PRICING IN CANADIAN DOLLARS Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: Acta-Embrace™ ATI Zero Elevation shown with GlideWear ® ATI - Adjustable Technology Insert Acta-Embrace™ ATI Anti-Thrust ACTA-EMBRACE-ATI-ORDER REV0418 DEPTH DEPTH WIDTH WIDTH EM-SZM-1824 EM-SZM-1924 EM-SZM-2024 EM-SZM-2124 EM-SZM-2224 EM-SZM-2324 EM-SZM-2424 EM-SZM-1823 EM-SZM-1923 EM-SZM-2023 EM-SZM-2123 EM-SZM-2223 EM-SZM-2323 EM-SZM-2423 EM-SZM-1622 EM-SZM-1722 EM-SZM-1822 EM-SZM-1922 EM-SZM-2022 EM-SZM-2122 EM-SZM-2222 EM-SZM-2322 EM-SZM-2422 EM-SZM-1521 EM-SZM-1621 EM-SZM-1721 EM-SZM-1821 EM-SZM-1921 EM-SZM-2021 EM-SZM-2121 EM-SZM-2221 EM-SZM-2321 EM-SZM-2421 EM-SZM-1420 EM-SZM-1520 EM-SZM-1620 EM-SZM-1720 EM-SZM-1820 EM-SZM-1920 EM-SZM-2020 EM-SZM-2120 EM-SZM-2220 EM-SZM-2320 EM-SZM-2420 EM-SZM-1419 EM-SZM-1519 EM-SZM-1619 EM-SZM-1719 EM-SZM-1819 EM-SZM-1919 EM-SZM-2019 EM-SZM-2119 EM-SZM-2219 EM-SZM-2319 EM-SZM-2419 EM-SZM-1218 EM-SZM-1318 EM-SZM-1418 EM-SZM-1518 EM-SZM-1618 EM-SZM-1718 EM-SZM-1818 EM-SZM-1918 EM-SZM-2018 EM-SZM-2118 EM-SZM-2218 EM-SZM-2318 EM-SZM-2418 EM-SZM-1117 EM-SZM-1217 EM-SZM-1317 EM-SZM-1417 EM-SZM-1517 EM-SZM-1617 EM-SZM-1717 EM-SZM-1817 EM-SZM-1917 EM-SZM-2017 EM-SZM-2117 EM-SZM-2217 EM-SZM-2317 EM-SZM-2417 EM-SZM-1016 EM-SZM-1116 EM-SZM-1216 EM-SZM-1316 EM-SZM-1416 EM-SZM-1516 EM-SZM-1616 EM-SZM-1716 EM-SZM-1816 EM-SZM-1916 EM-SZM-2016 EM-SZM-2116 EM-SZM-2216 EM-SZM-2316 EM-SZM-2416 EM-SZM-1015 EM-SZM-1115 EM-SZM-1215 EM-SZM-1315 EM-SZM-1415 EM-SZM-1515 EM-SZM-1615 EM-SZM-1715 EM-SZM-1815 EM-SZM-1915 EM-SZM-2015 EM-SZM-1014 EM-SZM-1114 EM-SZM-1214 EM-SZM-1314 EM-SZM-1414 EM-SZM-1514 EM-SZM-1614 EM-SZM-1714 EM-SZM-1814 EM-SZM-1914 EM-SZM-1013 EM-SZM-1113 EM-SZM-1213 EM-SZM-1313 EM-SZM-1413 EM-SZM-1513 EM-SZM-1613 EM-SZM-1713 EM-SZM-1012 EM-SZM-1112 EM-SZM-1212 EM-SZM-1312 EM-SZM-1412 EM-SZM-1512 EM-SZM-1612 EM-SZM-1712 EM-SZM-1011 EM-SZM-1111 EM-SZM-1211 EM-SZM-1311 EM-SZM-1411 EM-SZM-1511 EM-SZM-1010 EM-SZM-1110 EM-SZM-1210 EM-SZM-1310 EM-SZM-1410 EM-SZM-1510 EM-FZM-1824 EM-FZM-1924 EM-FZM-2024 EM-FZM-2124 EM-FZM-2224 EM-FZM-2324 EM-FZM-2424 EM-FZM-1823 EM-FZM-1923 EM-FZM-2023 EM-FZM-2123 EM-FZM-2223 EM-FZM-2323 EM-FZM-2423 EM-FZM-1622 EM-FZM-1722 EM-FZM-1822 EM-FZM-1922 EM-FZM-2022 EM-FZM-2122 EM-FZM-2222 EM-FZM-2322 EM-FZM-2422 EM-FZM-1521 EM-FZM-1621 EM-FZM-1721 EM-FZM-1821 EM-FZM-1921 EM-FZM-2021 EM-FZM-2121 EM-FZM-2221 EM-FZM-2321 EM-FZM-2421 EM-FZM-1420 EM-FZM-1520 EM-FZM-1620 EM-FZM-1720 EM-FZM-1820 EM-FZM-1920 EM-FZM-2020 EM-FZM-2120 EM-FZM-2220 EM-FZM-2320 EM-FZM-2420 EM-FZM-1419 EM-FZM-1519 EM-FZM-1619 EM-FZM-1719 EM-FZM-1819 EM-FZM-1919 EM-FZM-2019 EM-FZM-2119 EM-FZM-2219 EM-FZM-2319 EM-FZM-2419 EM-FZM-1218 EM-FZM-1318 EM-FZM-1418 EM-FZM-1518 EM-FZM-1618 EM-FZM-1718 EM-FZM-1818 EM-FZM-1918 EM-FZM-2018 EM-FZM-2118 EM-FZM-2218 EM-FZM-2318 EM-FZM-2418 EM-FZM-1117 EM-FZM-1217 EM-FZM-1317 EM-FZM-1417 EM-FZM-1517 EM-FZM-1617 EM-FZM-1717 EM-FZM-1817 EM-FZM-1917 EM-FZM-2017 EM-FZM-2117 EM-FZM-2217 EM-FZM-2317 EM-FZM-2417 EM-FZM-1016 EM-FZM-1116 EM-FZM-1216 EM-FZM-1316 EM-FZM-1416 EM-FZM-1516 EM-FZM-1616 EM-FZM-1716 EM-FZM-1816 EM-FZM-1916 EM-FZM-2016 EM-FZM-2116 EM-FZM-2216 EM-FZM-2316 EM-FZM-2416 EM-FZM-1015 EM-FZM-1115 EM-FZM-1215 EM-FZM-1315 EM-FZM-1415 EM-FZM-1515 EM-FZM-1615 EM-FZM-1715 EM-FZM-1815 EM-FZM-1915 EM-FZM-2015 EM-FZM-1014 EM-FZM-1114 EM-FZM-1214 EM-FZM-1314 EM-FZM-1414 EM-FZM-1514 EM-FZM-1614 EM-FZM-1714 EM-FZM-1814 EM-FZM-1914 EM-FZM-1013 EM-FZM-1113 EM-FZM-1213 EM-FZM-1313 EM-FZM-1413 EM-FZM-1513 EM-FZM-1613 EM-FZM-1713 EM-FZM-1012 EM-FZM-1112 EM-FZM-1212 EM-FZM-1312 EM-FZM-1412 EM-FZM-1512 EM-FZM-1612 EM-FZM-1712 EM-FZM-1011 EM-FZM-1111 EM-FZM-1211 EM-FZM-1311 EM-FZM-1411 EM-FZM-1511 EM-FZM-1010 EM-FZM-1110 EM-FZM-1210 EM-FZM-1310 EM-FZM-1410 EM-FZM-1510 21” 21” 14” 14” 22” 22” 15” 15” 23” 23” 16” 16” 10” 10” 18” 18” 14” 14” 22” 22” 11” 11” 19” 19” 15” 15” 23” 23” 12” 12” 20” 20” 16” 16” 24” 24” 13” 13” 21” 21” 17” 17” 20” 20” 13” 13” 19” 19” 12” 12” 18” 18” 11” 11” 10” 10” 24” 24” 17” 17” STRETCH-AIR™ COMFORT-TEK™ ACTA-EMBRACE™ ATI ORDER FORM Patient Reference: PAGE 1 of 7 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 sales.ca@permobil.com or 1.877.636.8944. SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION. SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE. STRETCH-AIR™ COMFORT-TEK™ OR ZERO ELEVATION Please select size in the appropriate fabric chart below.
Transcript of ACTA-EMBRACE ATI ORDER FORM - Permobil CA€¦ · ACTA-EMBRACE™ ATI ORDER FORM Patient Reference:...
$691.00
$691.00
$753.00
$753.00
SIZE & STYLE1
ACTA-EMBRACE® ATIORDER FORMPRICING IN CANADIAN DOLLARS Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
Acta-Embrace™ ATI Zero Elevation shown with GlideWear®
ATI - Adjustable Technology Insert
Acta-Embrace™ ATI Anti-Thrust
AC
TA-E
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-ATI
-OR
DE
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0418
DE
PTH
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WIDTH
EM-SZM-1824 EM-SZM-1924 EM-SZM-2024 EM-SZM-2124 EM-SZM-2224 EM-SZM-2324 EM-SZM-2424
EM-SZM-1823 EM-SZM-1923 EM-SZM-2023 EM-SZM-2123 EM-SZM-2223 EM-SZM-2323 EM-SZM-2423
EM-SZM-1622 EM-SZM-1722 EM-SZM-1822 EM-SZM-1922 EM-SZM-2022 EM-SZM-2122 EM-SZM-2222 EM-SZM-2322 EM-SZM-2422
EM-SZM-1521 EM-SZM-1621 EM-SZM-1721 EM-SZM-1821 EM-SZM-1921 EM-SZM-2021 EM-SZM-2121 EM-SZM-2221 EM-SZM-2321 EM-SZM-2421
EM-SZM-1420 EM-SZM-1520 EM-SZM-1620 EM-SZM-1720 EM-SZM-1820 EM-SZM-1920 EM-SZM-2020 EM-SZM-2120 EM-SZM-2220 EM-SZM-2320 EM-SZM-2420
EM-SZM-1419 EM-SZM-1519 EM-SZM-1619 EM-SZM-1719 EM-SZM-1819 EM-SZM-1919 EM-SZM-2019 EM-SZM-2119 EM-SZM-2219 EM-SZM-2319 EM-SZM-2419
EM-SZM-1218 EM-SZM-1318 EM-SZM-1418 EM-SZM-1518 EM-SZM-1618 EM-SZM-1718 EM-SZM-1818 EM-SZM-1918 EM-SZM-2018 EM-SZM-2118 EM-SZM-2218 EM-SZM-2318 EM-SZM-2418
EM-SZM-1117 EM-SZM-1217 EM-SZM-1317 EM-SZM-1417 EM-SZM-1517 EM-SZM-1617 EM-SZM-1717 EM-SZM-1817 EM-SZM-1917 EM-SZM-2017 EM-SZM-2117 EM-SZM-2217 EM-SZM-2317 EM-SZM-2417
EM-SZM-1016 EM-SZM-1116 EM-SZM-1216 EM-SZM-1316 EM-SZM-1416 EM-SZM-1516 EM-SZM-1616 EM-SZM-1716 EM-SZM-1816 EM-SZM-1916 EM-SZM-2016 EM-SZM-2116 EM-SZM-2216 EM-SZM-2316 EM-SZM-2416
EM-SZM-1015 EM-SZM-1115 EM-SZM-1215 EM-SZM-1315 EM-SZM-1415 EM-SZM-1515 EM-SZM-1615 EM-SZM-1715 EM-SZM-1815 EM-SZM-1915 EM-SZM-2015
EM-SZM-1014 EM-SZM-1114 EM-SZM-1214 EM-SZM-1314 EM-SZM-1414 EM-SZM-1514 EM-SZM-1614 EM-SZM-1714 EM-SZM-1814 EM-SZM-1914
EM-SZM-1013 EM-SZM-1113 EM-SZM-1213 EM-SZM-1313 EM-SZM-1413 EM-SZM-1513 EM-SZM-1613 EM-SZM-1713
EM-SZM-1012 EM-SZM-1112 EM-SZM-1212 EM-SZM-1312 EM-SZM-1412 EM-SZM-1512 EM-SZM-1612 EM-SZM-1712
EM-SZM-1011 EM-SZM-1111 EM-SZM-1211 EM-SZM-1311 EM-SZM-1411 EM-SZM-1511
EM-SZM-1010 EM-SZM-1110 EM-SZM-1210 EM-SZM-1310 EM-SZM-1410 EM-SZM-1510
EM-FZM-1824 EM-FZM-1924 EM-FZM-2024 EM-FZM-2124 EM-FZM-2224 EM-FZM-2324 EM-FZM-2424
EM-FZM-1823 EM-FZM-1923 EM-FZM-2023 EM-FZM-2123 EM-FZM-2223 EM-FZM-2323 EM-FZM-2423
EM-FZM-1622 EM-FZM-1722 EM-FZM-1822 EM-FZM-1922 EM-FZM-2022 EM-FZM-2122 EM-FZM-2222 EM-FZM-2322 EM-FZM-2422
EM-FZM-1521 EM-FZM-1621 EM-FZM-1721 EM-FZM-1821 EM-FZM-1921 EM-FZM-2021 EM-FZM-2121 EM-FZM-2221 EM-FZM-2321 EM-FZM-2421
EM-FZM-1420 EM-FZM-1520 EM-FZM-1620 EM-FZM-1720 EM-FZM-1820 EM-FZM-1920 EM-FZM-2020 EM-FZM-2120 EM-FZM-2220 EM-FZM-2320 EM-FZM-2420
EM-FZM-1419 EM-FZM-1519 EM-FZM-1619 EM-FZM-1719 EM-FZM-1819 EM-FZM-1919 EM-FZM-2019 EM-FZM-2119 EM-FZM-2219 EM-FZM-2319 EM-FZM-2419
EM-FZM-1218 EM-FZM-1318 EM-FZM-1418 EM-FZM-1518 EM-FZM-1618 EM-FZM-1718 EM-FZM-1818 EM-FZM-1918 EM-FZM-2018 EM-FZM-2118 EM-FZM-2218 EM-FZM-2318 EM-FZM-2418
EM-FZM-1117 EM-FZM-1217 EM-FZM-1317 EM-FZM-1417 EM-FZM-1517 EM-FZM-1617 EM-FZM-1717 EM-FZM-1817 EM-FZM-1917 EM-FZM-2017 EM-FZM-2117 EM-FZM-2217 EM-FZM-2317 EM-FZM-2417
EM-FZM-1016 EM-FZM-1116 EM-FZM-1216 EM-FZM-1316 EM-FZM-1416 EM-FZM-1516 EM-FZM-1616 EM-FZM-1716 EM-FZM-1816 EM-FZM-1916 EM-FZM-2016 EM-FZM-2116 EM-FZM-2216 EM-FZM-2316 EM-FZM-2416
EM-FZM-1015 EM-FZM-1115 EM-FZM-1215 EM-FZM-1315 EM-FZM-1415 EM-FZM-1515 EM-FZM-1615 EM-FZM-1715 EM-FZM-1815 EM-FZM-1915 EM-FZM-2015
EM-FZM-1014 EM-FZM-1114 EM-FZM-1214 EM-FZM-1314 EM-FZM-1414 EM-FZM-1514 EM-FZM-1614 EM-FZM-1714 EM-FZM-1814 EM-FZM-1914
EM-FZM-1013 EM-FZM-1113 EM-FZM-1213 EM-FZM-1313 EM-FZM-1413 EM-FZM-1513 EM-FZM-1613 EM-FZM-1713
EM-FZM-1012 EM-FZM-1112 EM-FZM-1212 EM-FZM-1312 EM-FZM-1412 EM-FZM-1512 EM-FZM-1612 EM-FZM-1712
EM-FZM-1011 EM-FZM-1111 EM-FZM-1211 EM-FZM-1311 EM-FZM-1411 EM-FZM-1511
EM-FZM-1010 EM-FZM-1110 EM-FZM-1210 EM-FZM-1310 EM-FZM-1410 EM-FZM-1510
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13”
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21”
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18”
11”
11”
10”
10”
24”
24”
17”
17”
STRETCH-AIR™
COMFORT-TEK™
ACTA-EMBRACE™ ATI ORDER FORM Patient Reference: PAGE 1 of 7
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.
SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION.
SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE.
STRETCH-AIR™ COMFORT-TEK™
ORZERO ELEVATION Please select size in the appropriate fabric chart below.
AC
TA-E
MB
RA
CE
-ATI
-OR
DE
R R
EV
0418
ACTA-EMBRACE™ ATI ORDER FORM Patient Reference: PAGE 2 of 7
$766.25
$766.25
$828.25
$828.25
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WIDTH
EM-SQZM-1824 EM-SQZM-1924 EM-SQZM-2024 EM-SQZM-2124 EM-SQZM-2224 EM-SQZM-2324 EM-SQZM-2424
EM-SQZM-1823 EM-SQZM-1923 EM-SQZM-2023 EM-SQZM-2123 EM-SQZM-2223 EM-SQZM-2323 EM-SQZM-2423
EM-SQZM-1622 EM-SQZM-1722 EM-SQZM-1822 EM-SQZM-1922 EM-SQZM-2022 EM-SQZM-2122 EM-SQZM-2222 EM-SQZM-2322 EM-SQZM-2422
EM-SQZM-1521 EM-SQZM-1621 EM-SQZM-1721 EM-SQZM-1821 EM-SQZM-1921 EM-SQZM-2021 EM-SQZM-2121 EM-SQZM-2221 EM-SQZM-2321 EM-SQZM-2421
EM-SQZM-1420 EM-SQZM-1520 EM-SQZM-1620 EM-SQZM-1720 EM-SQZM-1820 EM-SQZM-1920 EM-SQZM-2020 EM-SQZM-2120 EM-SQZM-2220 EM-SQZM-2320 EM-SQZM-2420
EM-SQZM-1419 EM-SQZM-1519 EM-SQZM-1619 EM-SQZM-1719 EM-SQZM-1819 EM-SQZM-1919 EM-SQZM-2019 EM-SQZM-2119 EM-SQZM-2219 EM-SQZM-2319 EM-SQZM-2419
EM-SQZM-1218 EM-SQZM-1318 EM-SQZM-1418 EM-SQZM-1518 EM-SQZM-1618 EM-SQZM-1718 EM-SQZM-1818 EM-SQZM-1918 EM-SQZM-2018 EM-SQZM-2118 EM-SQZM-2218 EM-SQZM-2318 EM-SQZM-2418
EM-SQZM-1117 EM-SQZM-1217 EM-SQZM-1317 EM-SQZM-1417 EM-SQZM-1517 EM-SQZM-1617 EM-SQZM-1717 EM-SQZM-1817 EM-SQZM-1917 EM-SQZM-2017 EM-SQZM-2117 EM-SQZM-2217 EM-SQZM-2317 EM-SQZM-2417
EM-SQZM-1016 EM-SQZM-1116 EM-SQZM-1216 EM-SQZM-1316 EM-SQZM-1416 EM-SQZM-1516 EM-SQZM-1616 EM-SQZM-1716 EM-SQZM-1816 EM-SQZM-1916 EM-SQZM-2016 EM-SQZM-2116 EM-SQZM-2216 EM-SQZM-2316 EM-SQZM-2416
EM-SQZM-1015 EM-SQZM-1115 EM-SQZM-1215 EM-SQZM-1315 EM-SQZM-1415 EM-SQZM-1515 EM-SQZM-1615 EM-SQZM-1715 EM-SQZM-1815 EM-SQZM-1915 EM-SQZM-2015
EM-SQZM-1014 EM-SQZM-1114 EM-SQZM-1214 EM-SQZM-1314 EM-SQZM-1414 EM-SQZM-1514 EM-SQZM-1614 EM-SQZM-1714 EM-SQZM-1814 EM-SQZM-1914
EM-SQZM-1013 EM-SQZM-1113 EM-SQZM-1213 EM-SQZM-1313 EM-SQZM-1413 EM-SQZM-1513 EM-SQZM-1613 EM-SQZM-1713
EM-SQZM-1012 EM-SQZM-1112 EM-SQZM-1212 EM-SQZM-1312 EM-SQZM-1412 EM-SQZM-1512 EM-SQZM-1612 EM-SQZM-1712
EM-SQZM-1011 EM-SQZM-1111 EM-SQZM-1211 EM-SQZM-1311 EM-SQZM-1411 EM-SQZM-1511
EM-SQZM-1010 EM-SQZM-1110 EM-SQZM-1210 EM-SQZM-1310 EM-SQZM-1410 EM-SQZM-1510
EM-FQZM-1824 EM-FQZM-1924 EM-FQZM-2024 EM-FQZM-2124 EM-FQZM-2224 EM-FQZM-2324 EM-FQZM-2424
EM-FQZM-1823 EM-FQZM-1923 EM-FQZM-2023 EM-FQZM-2123 EM-FQZM-2223 EM-FQZM-2323 EM-FQZM-2423
EM-FQZM-1622 EM-FQZM-1722 EM-FQZM-1822 EM-FQZM-1922 EM-FQZM-2022 EM-FQZM-2122 EM-FQZM-2222 EM-FQZM-2322 EM-FQZM-2422
EM-FQZM-1521 EM-FQZM-1621 EM-FQZM-1721 EM-FQZM-1821 EM-FQZM-1921 EM-FQZM-2021 EM-FQZM-2121 EM-FQZM-2221 EM-FQZM-2321 EM-FQZM-2421
EM-FQZM-1420 EM-FQZM-1520 EM-FQZM-1620 EM-FQZM-1720 EM-FQZM-1820 EM-FQZM-1920 EM-FQZM-2020 EM-FQZM-2120 EM-FQZM-2220 EM-FQZM-2320 EM-FQZM-2420
EM-FQZM-1419 EM-FQZM-1519 EM-FQZM-1619 EM-FQZM-1719 EM-FQZM-1819 EM-FQZM-1919 EM-FQZM-2019 EM-FQZM-2119 EM-FQZM-2219 EM-FQZM-2319 EM-FQZM-2419
EM-FQZM-1218 EM-FQZM-1318 EM-FQZM-1418 EM-FQZM-1518 EM-FQZM-1618 EM-FQZM-1718 EM-FQZM-1818 EM-FQZM-1918 EM-FQZM-2018 EM-FQZM-2118 EM-FQZM-2218 EM-FQZM-2318 EM-FQZM-2418
EM-FQZM-1117 EM-FQZM-1217 EM-FQZM-1317 EM-FQZM-1417 EM-FQZM-1517 EM-FQZM-1617 EM-FQZM-1717 EM-FQZM-1817 EM-FQZM-1917 EM-FQZM-2017 EM-FQZM-2117 EM-FQZM-2217 EM-FQZM-2317 EM-FQZM-2417
EM-FQZM-1016 EM-FQZM-1116 EM-FQZM-1216 EM-FQZM-1316 EM-FQZM-1416 EM-FQZM-1516 EM-FQZM-1616 EM-FQZM-1716 EM-FQZM-1816 EM-FQZM-1916 EM-FQZM-2016 EM-FQZM-2116 EM-FQZM-2216 EM-FQZM-2316 EM-FQZM-2416
EM-FQZM-1015 EM-FQZM-1115 EM-FQZM-1215 EM-FQZM-1315 EM-FQZM-1415 EM-FQZM-1515 EM-FQZM-1615 EM-FQZM-1715 EM-FQZM-1815 EM-FQZM-1915 EM-FQZM-2015
EM-FQZM-1014 EM-FQZM-1114 EM-FQZM-1214 EM-FQZM-1314 EM-FQZM-1414 EM-FQZM-1514 EM-FQZM-1614 EM-FQZM-1714 EM-FQZM-1814 EM-FQZM-1914
EM-FQZM-1013 EM-FQZM-1113 EM-FQZM-1213 EM-FQZM-1313 EM-FQZM-1413 EM-FQZM-1513 EM-FQZM-1613 EM-FQZM-1713
EM-FQZM-1012 EM-FQZM-1112 EM-FQZM-1212 EM-FQZM-1312 EM-FQZM-1412 EM-FQZM-1512 EM-FQZM-1612 EM-FQZM-1712
EM-FQZM-1011 EM-FQZM-1111 EM-FQZM-1211 EM-FQZM-1311 EM-FQZM-1411 EM-FQZM-1511
EM-FQZM-1010 EM-FQZM-1110 EM-FQZM-1210 EM-FQZM-1310 EM-FQZM-1410 EM-FQZM-1510
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18”
18”
14”
14”
22”
22”
11”
11”
19”
19”
15”
15”
23”
23”
12”
12”
20”
20”
16”
16”
24”
24”
13”
13”
21”
21”
17”
17”
20”
20”
13”
13”
19”
19”
12”
12”
18”
18”
11”
11”
10”
10”
24”
24”
17”
17”
STRETCH-AIR™ with GLIDEWEAR®
COMFORT-TEK™ with GLIDEWEAR®
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.265.9830
GLIDEWEAR® is designed to promote healing as well as reduce the risk of skin breakdown. A GlideWear® Shear Reduction Panel is incorporated into the cover under the most at-risk areas to allow for micro-movements without the deformation of tissue.
U.S. GLIDEWEAR® Patent No. 8,646,459
SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION.
STRETCH-AIR™ SELECTED FOR INCONTINENCE PROTECTION
& AN EASILY CLEANED SURFACE.
COMFORT-TEK™OR
ZERO ELEVATION with
Please select size in the appropriate fabric chart below.
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ACTA-EMBRACE™ ATI ORDER FORM Patient Reference: PAGE 3 of 7
$691.00
$691.00
$753.00
$753.00
DE
PTH
DE
PTH
WIDTH
WIDTH
EM-SAM-1824 EM-SAM-1924 EM-SAM-2024 EM-SAM-2124 EM-SAM-2224 EM-SAM-2324 EM-SAM-2424
EM-SAM-1823 EM-SAM-1923 EM-SAM-2023 EM-SAM-2123 EM-SAM-2223 EM-SAM-2323 EM-SAM-2423
EM-SAM-1622 EM-SAM-1722 EM-SAM-1822 EM-SAM-1922 EM-SAM-2022 EM-SAM-2122 EM-SAM-2222 EM-SAM-2322 EM-SAM-2422
EM-SAM-1521 EM-SAM-1621 EM-SAM-1721 EM-SAM-1821 EM-SAM-1921 EM-SAM-2021 EM-SAM-2121 EM-SAM-2221 EM-SAM-2321 EM-SAM-2421
EM-SAM-1420 EM-SAM-1520 EM-SAM-1620 EM-SAM-1720 EM-SAM-1820 EM-SAM-1920 EM-SAM-2020 EM-SAM-2120 EM-SAM-2220 EM-SAM-2320 EM-SAM-2420
EM-SAM-1419 EM-SAM-1519 EM-SAM-1619 EM-SAM-1719 EM-SAM-1819 EM-SAM-1919 EM-SAM-2019 EM-SAM-2119 EM-SAM-2219 EM-SAM-2319 EM-SAM-2419
EM-SAM-1218 EM-SAM-1318 EM-SAM-1418 EM-SAM-1518 EM-SAM-1618 EM-SAM-1718 EM-SAM-1818 EM-SAM-1918 EM-SAM-2018 EM-SAM-2118 EM-SAM-2218 EM-SAM-2318 EM-SAM-2418
EM-SAM-1117 EM-SAM-1217 EM-SAM-1317 EM-SAM-1417 EM-SAM-1517 EM-SAM-1617 EM-SAM-1717 EM-SAM-1817 EM-SAM-1917 EM-SAM-2017 EM-SAM-2117 EM-SAM-2217 EM-SAM-2317 EM-SAM-2417
EM-SAM-1016 EM-SAM-1116 EM-SAM-1216 EM-SAM-1316 EM-SAM-1416 EM-SAM-1516 EM-SAM-1616 EM-SAM-1716 EM-SAM-1816 EM-SAM-1916 EM-SAM-2016 EM-SAM-2116 EM-SAM-2216 EM-SAM-2316 EM-SAM-2416
EM-SAM-1015 EM-SAM-1115 EM-SAM-1215 EM-SAM-1315 EM-SAM-1415 EM-SAM-1515 EM-SAM-1615 EM-SAM-1715 EM-SAM-1815 EM-SAM-1915 EM-SAM-2015
EM-SAM-1014 EM-SAM-1114 EM-SAM-1214 EM-SAM-1314 EM-SAM-1414 EM-SAM-1514 EM-SAM-1614 EM-SAM-1714 EM-SAM-1814 EM-SAM-1914
EM-SAM-1013 EM-SAM-1113 EM-SAM-1213 EM-SAM-1313 EM-SAM-1413 EM-SAM-1513 EM-SAM-1613 EM-SAM-1713
EM-SAM-1012 EM-SAM-1112 EM-SAM-1212 EM-SAM-1312 EM-SAM-1412 EM-SAM-1512 EM-SAM-1612 EM-SAM-1712
EM-SAM-1011 EM-SAM-1111 EM-SAM-1211 EM-SAM-1311 EM-SAM-1411 EM-SAM-1511
EM-SAM-1010 EM-SAM-1110 EM-SAM-1210 EM-SAM-1310 EM-SAM-1410 EM-SAM-1510
EM-FAM-1824 EM-FAM-1924 EM-FAM-2024 EM-FAM-2124 EM-FAM-2224 EM-FAM-2324 EM-FAM-2424
EM-FAM-1823 EM-FAM-1923 EM-FAM-2023 EM-FAM-2123 EM-FAM-2223 EM-FAM-2323 EM-FAM-2423
EM-FAM-1622 EM-FAM-1722 EM-FAM-1822 EM-FAM-1922 EM-FAM-2022 EM-FAM-2122 EM-FAM-2222 EM-FAM-2322 EM-FAM-2422
EM-FAM-1521 EM-FAM-1621 EM-FAM-1721 EM-FAM-1821 EM-FAM-1921 EM-FAM-2021 EM-FAM-2121 EM-FAM-2221 EM-FAM-2321 EM-FAM-2421
EM-FAM-1420 EM-FAM-1520 EM-FAM-1620 EM-FAM-1720 EM-FAM-1820 EM-FAM-1920 EM-FAM-2020 EM-FAM-2120 EM-FAM-2220 EM-FAM-2320 EM-FAM-2420
EM-FAM-1419 EM-FAM-1519 EM-FAM-1619 EM-FAM-1719 EM-FAM-1819 EM-FAM-1919 EM-FAM-2019 EM-FAM-2119 EM-FAM-2219 EM-FAM-2319 EM-FAM-2419
EM-FAM-1218 EM-FAM-1318 EM-FAM-1418 EM-FAM-1518 EM-FAM-1618 EM-FAM-1718 EM-FAM-1818 EM-FAM-1918 EM-FAM-2018 EM-FAM-2118 EM-FAM-2218 EM-FAM-2318 EM-FAM-2418
EM-FAM-1117 EM-FAM-1217 EM-FAM-1317 EM-FAM-1417 EM-FAM-1517 EM-FAM-1617 EM-FAM-1717 EM-FAM-1817 EM-FAM-1917 EM-FAM-2017 EM-FAM-2117 EM-FAM-2217 EM-FAM-2317 EM-FAM-2417
EM-FAM-1016 EM-FAM-1116 EM-FAM-1216 EM-FAM-1316 EM-FAM-1416 EM-FAM-1516 EM-FAM-1616 EM-FAM-1716 EM-FAM-1816 EM-FAM-1916 EM-FAM-2016 EM-FAM-2116 EM-FAM-2216 EM-FAM-2316 EM-FAM-2416
EM-FAM-1015 EM-FAM-1115 EM-FAM-1215 EM-FAM-1315 EM-FAM-1415 EM-FAM-1515 EM-FAM-1615 EM-FAM-1715 EM-FAM-1815 EM-FAM-1915 EM-FAM-2015
EM-FAM-1014 EM-FAM-1114 EM-FAM-1214 EM-FAM-1314 EM-FAM-1414 EM-FAM-1514 EM-FAM-1614 EM-FAM-1714 EM-FAM-1814 EM-FAM-1914
EM-FAM-1013 EM-FAM-1113 EM-FAM-1213 EM-FAM-1313 EM-FAM-1413 EM-FAM-1513 EM-FAM-1613 EM-FAM-1713
EM-FAM-1012 EM-FAM-1112 EM-FAM-1212 EM-FAM-1312 EM-FAM-1412 EM-FAM-1512 EM-FAM-1612 EM-FAM-1712
EM-FAM-1011 EM-FAM-1111 EM-FAM-1211 EM-FAM-1311 EM-FAM-1411 EM-FAM-1511
EM-FAM-1010 EM-FAM-1110 EM-FAM-1210 EM-FAM-1310 EM-FAM-1410 EM-FAM-1510
21”
21”
14”
14”
22”
22”
15”
15”
23”
23”
16”
16”
10”
10”
18”
18”
14”
14”
22”
22”
11”
11”
19”
19”
15”
15”
23”
23”
12”
12”
20”
20”
16”
16”
24”
24”
13”
13”
21”
21”
17”
17”
20”
20”
13”
13”
19”
19”
12”
12”
18”
18”
11”
11”
10”
10”
24”
24”
17”
17”
STRETCH-AIR™
COMFORT-TEK™
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.265.9830
SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION.
STRETCH-AIR™ SELECTED FOR INCONTINENCE PROTECTION
& AN EASILY CLEANED SURFACE.
COMFORT-TEK™OR
ANTI-THRUSTPlease select size in the appropriate fabric chart below.
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TA-E
MB
RA
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ACTA-EMBRACE™ ATI ORDER FORM Patient Reference: PAGE 4 of 7
$766.25
$766.25
$828.25
$828.25
DE
PTH
DE
PTH
WIDTH
WIDTH
EM-SQAM-1824 EM-SQAM-1924 EM-SQAM-2024 EM-SQAM-2124 EM-SQAM-2224 EM-SQAM-2324 EM-SQAM-2424
EM-SQAM-1823 EM-SQAM-1923 EM-SQAM-2023 EM-SQAM-2123 EM-SQAM-2223 EM-SQAM-2323 EM-SQAM-2423
EM-SQAM-1622 EM-SQAM-1722 EM-SQAM-1822 EM-SQAM-1922 EM-SQAM-2022 EM-SQAM-2122 EM-SQAM-2222 EM-SQAM-2322 EM-SQAM-2422
EM-SQAM-1521 EM-SQAM-1621 EM-SQAM-1721 EM-SQAM-1821 EM-SQAM-1921 EM-SQAM-2021 EM-SQAM-2121 EM-SQAM-2221 EM-SQAM-2321 EM-SQAM-2421
EM-SQAM-1420 EM-SQAM-1520 EM-SQAM-1620 EM-SQAM-1720 EM-SQAM-1820 EM-SQAM-1920 EM-SQAM-2020 EM-SQAM-2120 EM-SQAM-2220 EM-SQAM-2320 EM-SQAM-2420
EM-SQAM-1419 EM-SQAM-1519 EM-SQAM-1619 EM-SQAM-1719 EM-SQAM-1819 EM-SQAM-1919 EM-SQAM-2019 EM-SQAM-2119 EM-SQAM-2219 EM-SQAM-2319 EM-SQAM-2419
EM-SQAM-1218 EM-SQAM-1318 EM-SQAM-1418 EM-SQAM-1518 EM-SQAM-1618 EM-SQAM-1718 EM-SQAM-1818 EM-SQAM-1918 EM-SQAM-2018 EM-SQAM-2118 EM-SQAM-2218 EM-SQAM-2318 EM-SQAM-2418
EM-SQAM-1117 EM-SQAM-1217 EM-SQAM-1317 EM-SQAM-1417 EM-SQAM-1517 EM-SQAM-1617 EM-SQAM-1717 EM-SQAM-1817 EM-SQAM-1917 EM-SQAM-2017 EM-SQAM-2117 EM-SQAM-2217 EM-SQAM-2317 EM-SQAM-2417
EM-SQAM-1016 EM-SQAM-1116 EM-SQAM-1216 EM-SQAM-1316 EM-SQAM-1416 EM-SQAM-1516 EM-SQAM-1616 EM-SQAM-1716 EM-SQAM-1816 EM-SQAM-1916 EM-SQAM-2016 EM-SQAM-2116 EM-SQAM-2216 EM-SQAM-2316 EM-SQAM-2416
EM-SQAM-1015 EM-SQAM-1115 EM-SQAM-1215 EM-SQAM-1315 EM-SQAM-1415 EM-SQAM-1515 EM-SQAM-1615 EM-SQAM-1715 EM-SQAM-1815 EM-SQAM-1915 EM-SQAM-2015
EM-SQAM-1014 EM-SQAM-1114 EM-SQAM-1214 EM-SQAM-1314 EM-SQAM-1414 EM-SQAM-1514 EM-SQAM-1614 EM-SQAM-1714 EM-SQAM-1814 EM-SQAM-1914
EM-SQAM-1013 EM-SQAM-1113 EM-SQAM-1213 EM-SQAM-1313 EM-SQAM-1413 EM-SQAM-1513 EM-SQAM-1613 EM-SQAM-1713
EM-SQAM-1012 EM-SQAM-1112 EM-SQAM-1212 EM-SQAM-1312 EM-SQAM-1412 EM-SQAM-1512 EM-SQAM-1612 EM-SQAM-1712
EM-SQAM-1011 EM-SQAM-1111 EM-SQAM-1211 EM-SQAM-1311 EM-SQAM-1411 EM-SQAM-1511
EM-SQAM-1010 EM-SQAM-1110 EM-SQAM-1210 EM-SQAM-1310 EM-SQAM-1410 EM-SQAM-1510
EM-FQAM-1824 EM-FQAM-1924 EM-FQAM-2024 EM-FQAM-2124 EM-FQAM-2224 EM-FQAM-2324 EM-FQAM-2424
EM-FQAM-1823 EM-FQAM-1923 EM-FQAM-2023 EM-FQAM-2123 EM-FQAM-2223 EM-FQAM-2323 EM-FQAM-2423
EM-FQAM-1622 EM-FQAM-1722 EM-FQAM-1822 EM-FQAM-1922 EM-FQAM-2022 EM-FQAM-2122 EM-FQAM-2222 EM-FQAM-2322 EM-FQAM-2422
EM-FQAM-1521 EM-FQAM-1621 EM-FQAM-1721 EM-FQAM-1821 EM-FQAM-1921 EM-FQAM-2021 EM-FQAM-2121 EM-FQAM-2221 EM-FQAM-2321 EM-FQAM-2421
EM-FQAM-1420 EM-FQAM-1520 EM-FQAM-1620 EM-FQAM-1720 EM-FQAM-1820 EM-FQAM-1920 EM-FQAM-2020 EM-FQAM-2120 EM-FQAM-2220 EM-FQAM-2320 EM-FQAM-2420
EM-FQAM-1419 EM-FQAM-1519 EM-FQAM-1619 EM-FQAM-1719 EM-FQAM-1819 EM-FQAM-1919 EM-FQAM-2019 EM-FQAM-2119 EM-FQAM-2219 EM-FQAM-2319 EM-FQAM-2419
EM-FQAM-1218 EM-FQAM-1318 EM-FQAM-1418 EM-FQAM-1518 EM-FQAM-1618 EM-FQAM-1718 EM-FQAM-1818 EM-FQAM-1918 EM-FQAM-2018 EM-FQAM-2118 EM-FQAM-2218 EM-FQAM-2318 EM-FQAM-2418
EM-FQAM-1117 EM-FQAM-1217 EM-FQAM-1317 EM-FQAM-1417 EM-FQAM-1517 EM-FQAM-1617 EM-FQAM-1717 EM-FQAM-1817 EM-FQAM-1917 EM-FQAM-2017 EM-FQAM-2117 EM-FQAM-2217 EM-FQAM-2317 EM-FQAM-2417
EM-FQAM-1016 EM-FQAM-1116 EM-FQAM-1216 EM-FQAM-1316 EM-FQAM-1416 EM-FQAM-1516 EM-FQAM-1616 EM-FQAM-1716 EM-FQAM-1816 EM-FQAM-1916 EM-FQAM-2016 EM-FQAM-2116 EM-FQAM-2216 EM-FQAM-2316 EM-FQAM-2416
EM-FQAM-1015 EM-FQAM-1115 EM-FQAM-1215 EM-FQAM-1315 EM-FQAM-1415 EM-FQAM-1515 EM-FQAM-1615 EM-FQAM-1715 EM-FQAM-1815 EM-FQAM-1915 EM-FQAM-2015
EM-FQAM-1014 EM-FQAM-1114 EM-FQAM-1214 EM-FQAM-1314 EM-FQAM-1414 EM-FQAM-1514 EM-FQAM-1614 EM-FQAM-1714 EM-FQAM-1814 EM-FQAM-1914
EM-FQAM-1013 EM-FQAM-1113 EM-FQAM-1213 EM-FQAM-1313 EM-FQAM-1413 EM-FQAM-1513 EM-FQAM-1613 EM-FQAM-1713
EM-FQAM-1012 EM-FQAM-1112 EM-FQAM-1212 EM-FQAM-1312 EM-FQAM-1412 EM-FQAM-1512 EM-FQAM-1612 EM-FQAM-1712
EM-FQAM-1011 EM-FQAM-1111 EM-FQAM-1211 EM-FQAM-1311 EM-FQAM-1411 EM-FQAM-1511
EM-FQAM-1010 EM-FQAM-1110 EM-FQAM-1210 EM-FQAM-1310 EM-FQAM-1410 EM-FQAM-1510
21”
21”
14”
14”
22”
22”
15”
15”
23”
23”
16”
16”
10”
10”
18”
18”
14”
14”
22”
22”
11”
11”
19”
19”
15”
15”
23”
23”
12”
12”
20”
20”
16”
16”
24”
24”
13”
13”
21”
21”
17”
17”
20”
20”
13”
13”
19”
19”
12”
12”
18”
18”
11”
11”
10”
10”
24”
24”
17”
17”
STRETCH-AIR™ with GLIDEWEAR®
COMFORT-TEK™ with GLIDEWEAR®
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.265.9830
GLIDEWEAR® is designed to promote healing as well as reduce the risk of skin breakdown. A GlideWear® Shear Reduction Panel is incorporated into the cover under the most at-risk areas to allow for micro-movements without the deformation of tissue.
U.S. GLIDEWEAR® Patent No. 8,646,459
SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION.
STRETCH-AIR™ SELECTED FOR INCONTINENCE PROTECTION
& AN EASILY CLEANED SURFACE.
COMFORT-TEK™OR
ANTI-THRUST with
Please select size in the appropriate fabric chart below.
B = 1” Rail Cut (RAIL-CUT-1.0)
B = 1½” Rail Cut (RAIL-CUT-1.5)
B = 2” Rail Cut (RAIL-CUT-2.0)
2.7REMOVABLE SOLID SEAT PAN & HARDWARE KITMSRP $625.00
Rigid Insert(RIDwwdd) indicate width & depth, ie. wwdd = 1620
2.8 RIGID INSERTMSRP $86.25
The solid seat pan kit includes a slotted aluminum pan and attaching hardware to accommodate 7/8” or 1” tubing. The kit also comes with two different cross bars to accommodate various wheelchair frame types. This will fit both folding and non-folding seat rails. Lateral thigh support hardware can be easily attached.
3/16” Plastic rigidizing board.
2
C = 1” D (GROWTH-NOTCH-1)
C = 2” D (GROWTH-NOTCH-2)
C = 3” D (GROWTH-NOTCH-3)
C =Other(GROWTH-NOTCH-OTHER)
2.1 GROWTH NOTCHESMSRP $0.00
If growth notches are selected, a 1¼” wide cut will be taken from each side to allow the cushion to fit between the chair canes.
DEPTH OF NOTCHES
C
TOP VIEW
1¼”
2.5 INCONTINENCE LINERMSRP One = $114.58 - Two = $229.16
Liner provides extra incontinence protection for the cushion.
One Extra Incontinence Liner (INCON-LINER)
Two Extra Incontinence Liners (INCON-LINER)
2.6 EXTRA COVERMSRP One = $119.79 - Two = $239.58
One Extra Stretch Air Outer Cover (X-STRETCH-AIR-CV)
Two Extra Stretch Air Outer Cover (2X-STRETCH-AIR-CV)
One Extra Comfort Tek Outer Cover (X-COMFORT-TEK-CV)
Two Extra Comfort Tek Outer Cover (2X-COMFORT-TEK-CV)
2.3COLOR - COMES STANDARDSILVER REFLECTIVE PIPING MSRP $52.08
Accent colors can be applied to the cushion via colored piping. If no colors are selected, our standard silver reflective piping is used.
Red (RED) Blue (BLUE)
Purple (PURPLE) Green (GREEN)
Pink (PINK) Remove (REMOVE)
Orange (ORANGE)
COLOR LOCATION
2.2 RAIL CUTSMSRP $52.08
A standard 1 1/2” wide cut will be made and you decide how high the cut will need to be. All cuts run the entire depth of the cushion.
FRONT
B
1½”
Kwik Strap®
(KWIK-STRAP)
2.4 KWIK STRAP®
MSRP $31.25
Kwik Strap® provides extra security. Kwik Strap® is connected to the bottom of the cushion via hook & loop attachment and wraps around vertical canes to secure the cushion to wheelchair during transfers.
Rear View
*All accessories are cosmetic changes to the cushionexcept for options in gray, which are add on items.
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ACTA-EMBRACE™ ATI ORDER FORM Patient Reference: PAGE 5 of 7
ACTA-EMBRACE™ ACCESSORIES
Solid Seat Pan & Hardware Kit(RSSP-1-wwdd) indicate width & depth, ie. wwdd = 1113
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ACTA-EMBRACE™ ATI ORDER FORM Patient Reference: PAGE 6 of 7
3
LD
AN
TI-T
HR
UST
3”L x 4”D BL-LPTSP1A-3L4D-LH BL-LPTSP1A-3L4D-LH BL-LPTSP1A-3L4D-RH BL-LPTSP1A-3L4D-RH
3”L x 5”D BL-LPTSP1A-3L5D-LH BL-LPTSP1A-3L5D-LH BL-LPTSP1A-3L5D-RH BL-LPTSP1A-3L5D-RH
4”L x 4”D BL-LPTSP1A-4L4D-LH BL-LPTSP1A-4L4D-LH BL-LPTSP1A-4L4D-RH BL-LPTSP1A-4L4D-RH
4”L x 6”D BL-LPTSP1A-4L6D-LH BL-LPTSP1A-4L6D-LH BL-LPTSP1A-4L6D-RH BL-LPTSP1A-4L6D-RH
4”L x 8”D BL-LPTSP1A-4L8D-LH BL-LPTSP1A-4L8D-LH BL-LPTSP1A-4L8D-RH BL-LPTSP1A-4L8D-RH
4”L x 10”D BL-LPTSP1A-4L10D-LH BL-LPTSP1A-4L10D-LH BL-LPTSP1A-4L10D-RH BL-LPTSP1A-4L10D-RH
4”L x 12”D BL-LPTSP1A-4L12D-LH BL-LPTSP1A-4L12D-LH BL-LPTSP1A-4L12D-RH BL-LPTSP1A-4L12D-RH
4”L x 14”D BL-LPTSP1A-4L14D-LH BL-LPTSP1A-4L14D-LH BL-LPTSP1A-4L14D-RH BL-LPTSP1A-4L14D-RH
4”L x 16”D BL-LPTSP1A-4L16D-LH BL-LPTSP1A-4L16D-LH BL-LPTSP1A-4L16D-RH BL-LPTSP1A-4L16D-RH
5”L x 7”D BL-LPTSP1A-5L7D-LH BL-LPTSP1A-5L7D-LH BL-LPTSP1A-5L7D-RH BL-LPTSP1A-5L7D-RH
STYLE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
ZE
RO
ELE
VA
TIO
N
3”L x 4”D BL-LPTSP1Z-3L4D-LH BL-LPTSP1Z-3L4D-LH BL-LPTSP1Z-3L4D-RH BL-LPTSP1Z-3L4D-RH
3”L x 5”D BL-LPTSP1Z-3L5D-LH BL-LPTSP1Z-3L5D-LH BL-LPTSP1Z-3L5D-RH BL-LPTSP1Z-3L5D-RH
4”L x 4”D BL-LPTSP1Z-4L4D-LH BL-LPTSP1Z-4L4D-LH BL-LPTSP1Z-4L4D-RH BL-LPTSP1Z-4L4D-RH
4”L x 6”D BL-LPTSP1Z-4L6D-LH BL-LPTSP1Z-4L6D-LH BL-LPTSP1Z-4L6D-RH BL-LPTSP1Z-4L6D-RH
4”L x 8”D BL-LPTSP1Z-4L8D-LH BL-LPTSP1Z-4L8D-LH BL-LPTSP1Z-4L8D-RH BL-LPTSP1Z-4L8D-RH
4”L x 10”D BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-RH BL-LPTSP1Z-4L10D-RH
4”L x 12” D BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-RH BL-LPTSP1Z-4L12D-RH
4”L x 14” D BL-LPTSP1Z-4L14D-LH BL-LPTSP1Z-4L14D-LH BL-LPTSP1Z-4L14D-RH BL-LPTSP1Z-4L14D-RH
4”L x 16” D BL-LPTSP1Z-4L16D-LH BL-LPTSP1Z-4L16D-LH BL-LPTSP1Z-4L16D-RH BL-LPTSP1Z-4L16D-RH
5”L x 7” D BL-LPTSP1Z-5L7D-LH BL-LPTSP1Z-5L7D-LH BL-LPTSP1Z-5L7D-RH BL-LPTSP1Z-5L7D-RH
LD
Please select sizes in the appropriate fabric & style charts below. Contact Customer Support for custom sizes that are not listed below. 1.800.265.9830.
OR
3.1BASIC PAD SIZE & SHAPEMSRP $208.33
*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.
• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.1.• Follow each column down to section 3.2 and select a style and cover for each pad selected insection 3.1.
COVER OPTIONS MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
COMFORT-TEK™ $0.00/ea. LPTS-P1-COMFORT LPTS-P1-COMFORT LPTS-P1-COMFORT LPTS-P1-COMFORT
STRETCH-AIR™ $0.00/ea. LPTS-P1-STRETCH LPTS-P1-STRETCH LPTS-P1-STRETCH LPTS-P1-STRETCH
GLIDEWEAR® $32.50/ea. LPTS-P1-GLIDE LPTS-P1-GLIDE LPTS-P1-GLIDE LPTS-P1-GLIDE
FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.
STRETCH-AIR™FOR AIR TRANSMISSION
& HEAT DISSIPATION.
COMFORT-TEK™FOR FLUID PROTECTION & AN
EASILY CLEANED SURFACE.
3.2 BASIC PAD COVER
3.3
TT HARDWARE, SLOT MOUNTA.
BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE
SIZE MSRP LEFT *EXTRA LEFT RIGHT * EXTRA RIGHT
FIX
ED
SMALL $197.92 BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-RH BL-LPTS-TT1FXSL1-RH
MEDIUM $197.92 BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-RH BL-LPTS-TT1FXSL2-RH
LARGE $197.92 BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-RH BL-LPTS-TT1FXSL3-RH
RE
MO
VA
BLE SMALL $281.25 BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-RH BL-LPTS-TT1RMSL1-RH
MEDIUM $281.25 BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-RH BL-LPTS-TT1RMSL2-RH
LARGE $281.25 BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-RH BL-LPTS-TT1RMSL3-RH
OR
HARDWARE SIZEMAX CUSHION
THICKNESS CLEARANCE
RECOMMENDED CUSHION
THICKNESS
SMALL 3.0” 2.0”- 3.0”
MEDIUM 4.5” 3.0”- 4.5”
LARGE 6.5” 4.0”- 6.5”
TT
HA
RD
WA
RE
S
LO
T M
OU
NT
- F
IXE
D
TT
HA
RD
WA
RE
S
LO
T M
OU
NT
- R
EM
OV
AB
LE
SMALL MEDIUM LARGE
HARDWARE SIZE V. CUSHION THICKNESS
2.0”- 3.0”
3.0”- 4.5”
4.0”- 6.5”
• You may make one selection per column (Left, Extra Left, Right, and Extra Right) insection 3.3 from group A, B, -OR- C.
• TT long extention arms (section 3.4) will only work with TT style hardware.• GT hardware extra links (section 3.4) will only work with GT style hardware.
BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE & PADS
AC
TA-E
MB
RA
CE
-ATI
-OR
DE
R R
EV
0418
TT
HA
RD
WA
RE
P
OW
ER
MO
UN
T-
FIX
ED
TT
HA
RD
WA
RE
P
OW
ER
MO
UN
T-
RE
MO
VA
BL
E
SMALL MEDIUM LARGE
HARDWARE SIZE V. CUSHION THICKNESS
2.0”- 3.5”
3.0”- 5.5”
4.0”- 7.5”TT HARDWARE, POWER MOUNTB.
HARDWARE SIZEMAX CUSHION
THICKNESS CLEARANCE
RECOMMENDED CUSHION
THICKNESS
SMALL 3.5” 2.0”- 3.5”
MEDIUM 5.5” 3.0”- 5.5”
LARGE 7.5” 4.0”- 7.5”
SIZE MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
FIX
ED
SMALL $255.21 BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-RH BL-LPTS-TT1FXPWL1-RH
MEDIUM $255.21 BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-RH BL-LPTS-TT1FXPWL2-RH
LARGE $255.21 BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-RH BL-LPTS-TT1FXPWL3-RH
RE
MO
VA
BLE SMALL $333.33 BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-RH BL-LPTS-TT1RMPWL1-RH
MEDIUM $333.33 BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-RH BL-LPTS-TT1RMPWL2-RH
LARGE $333.33 BL-LPTS-TT1RMPWL3-LH BL-LPTS-TT1RMPWL3-LH BL-LPTS-TT1RMPWL3-RH BL-LPTS-TT1RMPWL3-RH
OR
NOTE: If choosing the Power Mount Hardware, choose the appropriate power mount type below.
POWER MOUNT MSRP PART NUMBER
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
TT HARDWARE, POWER MOUNT OPTION
GT HARDWARE (ONLY SLOT MOUNT)
SIZE MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
FIXED $197.92 BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-RH BL-LPTS-GT2FXS-RH
REMOVABLE $387.50 BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-RH BL-LPTS-GT2RMS-RH
C.
GT
HA
RD
WA
RE
S
LO
T M
OU
NT
- F
IXE
D
GT
HA
RD
WA
RE
S
LO
T M
OU
NT
- R
EM
OV
AB
LE
HARDWAREMAX CUSHION
THICKNESS CLEARANCE
RECOMMENDED CUSHION
THICKNESS
NO MEDIAL *5.0” 2.5”- 5.0”
1” MEDIAL *4.0” 2.25”- 4.0”
*If you need to increase the height or medial reach, add additional links in section 2.2.
NO
ME
DIA
L
1” M
ED
IAL
3.4 ADDITIONAL OPTIONS
TT LONG EXTENSION ARM 4” LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
MSRP $52.08/arm BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4
GT ADDITIONAL HARDWARE LINKS
LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
MSRP $52.08/link(2 Additional 1.25” Links Allowed
Per Hardware Ordered)
BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK
BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK
ACTA-EMBRACE™ ATI ORDER FORM Patient Reference: PAGE 7 of 7
