ORDER FOR CONTINUANCE DC 1:2.2 Rev. 05/19 Neb. Rev. Stat ...
PinDot Series ContourU Order Form Rev. 3/1/11
3
PinDot Series ContourU Order Form Rev. 3/1/11 Send Cast / Splint and Order Form to Pindot Custom Seating Attn: ContourU, 899 Cleveland St. Elyria, OH 44036 For Skribbl'r Digitizing Systems: E-mail Order Form and Digitized File to: Molding Bag Measurements Mobility Base Information / Cushion Dimensions Is This Order Going "With Chair" (NEW Invacare Chair) * Is This Order Going "On Chair" (NEW Invacare Chair) * * When ordering cushions "With Chair" / "On Chair" fax this Center Shapes or Leave as Marked order form and the order for the Invacare Chair to: Pindot Customer Service at 1-800-834-4153 If Invacare quote is to be converted to order, please provide Invacare quote # If Freedom wheelchair order will be shipped to Invacare for install, please give order # Accessories HR01S* Small Headrest includes Adapter Plate SB05 ContourU Pelvic Strap HR02S* Large Headrest includes Adapter Plate AR20 Desk Length Armrest (Pair) HR03S* 2-Step Headrest includes Adapter Plate AR24 Full Length Armrest (Pair) HR04S* Curved Headrest includes Adapter Plate LB07 Small Footrest (Pair) HR15 Headrest Adapter Plate * ** LB08 Large Footrest (Pair) * HR15 Required when using Contour U pan LT06 Legrest Tops (Pair) ** Will not work with Freedon t-nut pattern GL01 Regular Links TR40L Tray Receptacle - Left GL03 Extra Strong Links TR40R Tray Receptacle - Right GL10 Dial Links - Required if seat to back angle is > 105 Seat to Back Junctions Comments and Special Instructions $128.00 $128.00 $125.00 $225.00 $210.00 No Full Full Only $225.00 $322.00 $225.00 $322.00 $38.00 $210.00 $110.00 Inches of Gap Std. $40.00 $322.00 $225.00 N/A Seat Cushion Width: Brand: in Back Tube Diameter: Back Cushion Width: N/A N/A Junction Growth in Inches Std. Hip Control Universal Open to Rear Inside Rail Width: Inside Back Cane Width: in in Seat Tube Diameter Pelvic Control Model: Frame Depth: in Frame Width: in in in in F / (1) Seat-Back Angle, in Degrees = Back Height G / (1) Top of Lateral Height-Right E / (1) Leg Length / Left D / (1) Leg Length / Right B / (2) Waist Width C / (2) Hip Width A / (2) Chest Width N/A Account #: Penny Location/ # of Pennies Description Molding Bag: Client Reference: Purchase Order #: Certification #: Fax Number: Contact Name: Phone Number: Best Time to Contact: Ship To Address: E-mail Address: City/State/Zip: Company Name: [email protected] Date: For ease of ordering, contact Pindot Customer Service Toll Free at: 800-451-3553 Fax: 800-834-4153 Cell Phone Number: Modify To: N/A N/A H / (1) Top of Lateral Height-Left N/A Center Lines: N/A Fixed Recline (>105) $322.00 Full Tongue Tongue Full Tongue Style of Gap Yes Custom Seating
Transcript of PinDot Series ContourU Order Form Rev. 3/1/11
PinDot Series ContourU Order Form Rev. 3/1/11
Send Cast / Splint and Order Form to Pindot Custom SeatingAttn: ContourU, 899 Cleveland St. Elyria, OH 44036
For Skribbl'r Digitizing Systems: E-mail Order Form and Digitized File to:
Molding Bag MeasurementsMobility Base Information / Cushion Dimensions
Is This Order Going "With Chair" (NEW Invacare Chair) *Is This Order Going "On Chair" (NEW Invacare Chair) *
* When ordering cushions "With Chair" / "On Chair" fax thisCenter Shapes or Leave as Marked order form and the order for the Invacare Chair to:
Pindot Customer Service at 1-800-834-4153
If Invacare quote is to be converted to order, please provide Invacare quote # If Freedom wheelchair order will be shipped to Invacare for install, please give order #
AccessoriesHR01S* Small Headrest includes Adapter Plate SB05 ContourU Pelvic StrapHR02S* Large Headrest includes Adapter Plate AR20 Desk Length Armrest (Pair)HR03S* 2-Step Headrest includes Adapter Plate AR24 Full Length Armrest (Pair)HR04S* Curved Headrest includes Adapter Plate LB07 Small Footrest (Pair)HR15 Headrest Adapter Plate *
** LB08 Large Footrest (Pair)* HR15 Required when using Contour U pan LT06 Legrest Tops (Pair)** Will not work with Freedon t-nut pattern GL01 Regular Links
TR40L Tray Receptacle - Left GL03 Extra Strong LinksTR40R Tray Receptacle - Right GL10 Dial Links - Required if seat to back angle is > 105
Seat to Back Junctions
Comments and Special Instructions
$128.00$128.00 $125.00
$225.00$210.00
No FullFull Only
$225.00$322.00$225.00
$322.00$38.00
$210.00
$110.00
Inches of Gap
Std.
$40.00$322.00
$225.00
N/A
Seat Cushion Width:
Brand:
inBack Tube Diameter:Back Cushion Width:
N/A N/A
Junction Growth in InchesStd.
Hip ControlUniversal
Open to Rear
Inside Rail Width: Inside Back Cane Width:ininSeat Tube Diameter
Pelvic Control
Model:Frame Depth:inFrame Width:
in
ininin
F / (1)
Seat-Back Angle, in Degrees =
Back HeightG / (1) Top of Lateral Height-Right
E / (1) Leg Length / LeftD / (1) Leg Length / Right
B / (2) Waist WidthC / (2) Hip Width
A / (2) Chest Width N/A
Account #:
Penny Location/ # of Pennies Description Molding
Bag:
Client Reference: Purchase Order #:Certification #: Fax Number:
Contact Name:
Phone Number:
Best Time to Contact:Ship To Address: E-mail Address:
City/State/Zip:
Company Name:
Date:
For ease of ordering, contact Pindot Customer Service Toll Free at: 800-451-3553 Fax: 800-834-4153
Cell Phone Number:
Modify To:
N/AN/A
H / (1) Top of Lateral Height-LeftN/A
Center Lines:
N/AFixed Recline (>105)
$322.00
FullTongueTongue FullTongue
Style of Gap
Yes
C u s tom S ea tin g
Seat Cushion Specifications Standard Foam Soft FoamCovering Options
CM02S Naked (Drawstring Cloth Cover Included)
Mounting Optional Cover StyleDraw String (Std)
If Leg Length Discrepancy, Size Pan to fit: 2 Piece w/VelcroShort Leg or Long Leg
CTNP Pindot to cut pan to fit Long Leg Mounting Hardware
Specify Non-Std T-Nut Pattern: * Wood Stiffeners are Std on Cushions Without a Wood Mount * Not Recommended for Invacare Solara. May Effect Seat to Back Junction.
Seat ModificationsCM22 Rail Cut - Finished Rail Cut Width = "CM38 Loose Fit (1/4" Increments) "CM13 Undercut - Right "CM13 Undercut - Left "
Show Placement on Cast/Image for These Modifications:CM40 Diagonal Cut Provide DimensionsCM12 Pelvic Strap Notches, 2" StandardCM33 Cross-Brace Notches, Provide DimensionsCM17 Notched Rear Corners, 1" x 2" StandardCTNP Pindot to cut pan for notched corners
CM50 Laminated Reinforcement CM20 Strap Slots 1/2" x 1 1/2" Standard - Naked Only
CM80 Aluminum Reinforced
CM23 Front Rigging Notches
VF05 Visco Foam Overlay 1/2" SF05 Standard Sofspot Foam Overlay 1/2"VF01 Visco Foam Overlay 1" SF01 Standard Sofspot Foam Overlay 1"
Comments and Special Instructions
For Office use Only
$95.00
L-15 Teal Rubber Backed Lycra
Adductor - Left
inchesCM36 Extendedinches
$95.00Adductor Reinforcement
inchesCM54 As Molded
Abductor
CM48 Standard L - Shaped Reinforcement
$125.00$65.00CM31 Upholstered Bottom without Velcro
CM31V Upholstered Bottom with Velcro
$95.00
$250.00$95.00
Name:After Roll
inches
$250.00$300.00
Digital File
CM47 Raised
$135.00
CM36 Extended
$95.00CM46 As Molded
L-06 Gray Rubber Backed LycraGMV Gunmetal Gray Vinyl
QtyCM78S Additional Cover for Vinyl Cushion
Additional Cloth Covers
WWV Wedgewood Blue Vinyl
PGV Purple Gray Vinyl
SAV Sage Green VinylTAV Taupe Vinyl
Adductor - Right
$95.00$95.00
CM47 RaisedCM46 As Molded
$160.00
$195.00
L-20 Blue Rubber Backed LycraL-23 Green Rubber Backed Lycra
$75.00
$195.00
$190.00
L-24 Spacer Mesh Fabric
$160.00
L-13 Light Blue Rubber Backed Lycra
DT-2 Standard Dartex
$95.00
CM30G Recess with Gel Pad Insert$95.00
$150.00Qty:
Qty:
L-19 Burgundy Rubber Backed LycraL-18 Purple Rubber Backed Lycra
L-14 Red Rubber Backed Lycra
L-05 Black Rubber Backed Lycra
CMS Lycra
DT-2R Reversed Dartex
$55.00
$210.00CM30 Recess Only
1 or 2 inchCM09V Sofspot - Visco Foam
Returned Cushions
$205.00
OCMK78 J & L Brackets-7/8 inch (railcut recommended)
$205.00$205.00HWPMK78 Pan Mounting Kit - 7/8 inch
$175.00$205.00HWWMK78 Wood Mounting Kit - 7/8 inch
HWWMK01 Wood Mounting Kit - 1 inch
HWPMK01 Pan Mounting Kit - 1 inch
$637.00$175.00
FDI-538 Econo-Eze (includes Seat & Back Hardware)*
$125.00
$135.00
CM09P Duplicate Sofspot Pad (Vinyl Only)Depth:1 or 2 inch
Depth:Qty:
Set-UpPull
RailCutWidth
Depth:
AuditLong/Short Length
Serial No. Intake
Width:
1 or 2 inch Depth:CM09 Sofspot - Std Foam
Splint
$250.00
$65.00
Calib.
Fabric: CM76S Additional Cover for Naked Cushion
SO40 Inner Moisture Resistant Cover
CMD Darlexx
QtyCMP Polartek
$1,170.00BKV Black Vinyl
$1,170.00CM01S Vinyl Upholstery (Non Removable)Qty
inches
Length:
# of Cushions
CM34 Extended
$125.00
Seat Width: inchesSeat Length:
CM06 Wood Mount without T-Nuts
TFNP New Pan
CM03 Untrimmed (vinyl only)
$75.00
$150.00$200.00
Cast
inches
CM06T Wood Mount with T-Nuts
TFEP To Fit Existing Pan:
OCMK01 J & L Brackets -1 inch (railcut recommended)
CM37 Raised
inches
Overlays only available on Naked Cushion
When opting for a 2- tone
fabric selection indicate "A" for contact surface, "B" for non-
contact surfaces
Back Cushion Specifications Standard Foam Soft FoamCovering Options
CM02B Naked (Drawstring Cloth Cover Included)
Optional Cover StyleDraw String (Std)2 Piece w/Velcro
Mounting Mounting Hardware
FDI-596 Econo-Eze (Back Hardware Only)Specify Non-Std T-Nut Pattern: * Not Recommended for Invacare Solara. May Effect Seat to Back Junction.
* Wood Stiffeners are Std on All Cushions Without a Wood Mount
Back ModificationsCM22 Rail Cut - Finished Rail Cut Width = "CM38 Loose Fit (1/4" Increments) "CM13 Undercut "CM40 Diagonal Cut "
CM20 Strap Slots 1/2" x 1 1/2" Standard - Naked Only
Strap Slots Available on Naked Only and Cannot Intersect a Sofspot
CM39 Laminated ReinforcementCM21 Aluminum ReinforcedCM534R Swing Away Lateral Right (Naked Only)**
CM534L Swing Away Lateral Left (Naked Only)**
VF05 Visco Foam Overlay 1/2" SF05 Standard Sofspot Foam Overlay 1/2"VF01 Visco Foam Overlay 1" SF01 Standard Sofspot Foam Overlay 1"
Comments and Special Instructions
For Office use Only Form # 00-284 v.1.91
$250.00$200.00
$135.00
$210.00$95.00
$150.00
$250.00
$65.00
$150.00
After Roll
Digital File
Cast Returned Cushions Splint
$300.00
L-19 Burgundy Rubber Backed Lycra
FDI-538 Econo-Eze (includes Seat & Back Hardware)*
$575.00$575.00
inches
inchesinches
$95.00
HWPMK01 Pan Mounting Kit - 1 inch
L-13 Light Blue Rubber Backed Lycra
$596.00
CMS LycraCMD Darlexx
L-24 Spacer Mesh Fabric
L-06 Gray Rubber Backed Lycra
$205.00
L-05 Black Rubber Backed Lycra
L-20 Blue Rubber Backed Lycra
L-14 Red Rubber Backed Lycra
$175.00$637.00
$175.00
L-18 Purple Rubber Backed Lycra
L-23 Green Rubber Backed Lycra
$250.00
QtyCMP Polartek
$1,170.00
$160.00$160.00
CM06 Wood Mount without T-Nuts
** Swing Away Laterals must be accompanied by CM21
$195.00
$65.00
$135.00
CM31 Upholstered Bottom without VelcroCM31V Upholstered Bottom with Velcro
$275.00
$190.00SO40 Inner Moisture Resistant Cover
$55.00
TFEP To Fit Existing Pan:
GMV Gunmetal Gray Vinyl
TFCS-Fit to Custom Shell:
CM78S Additional Cover for Vinyl CushionQty
CM06T Wood Mount with T-Nuts
Lateral ReinforcementCM16 Standard L - Shaped Reinforcement
$95.00CM51 Square Pull
CM09V Sofspot - Visco Foam1 or 2 inch
inches
DT-2 Standard Dartex DT-2R Reversed Dartex
Length Name:
CM30 Recess Only Qty:
Tongue
Rail Cut Intake Serial No. # of Cushions
Calib. Width Set-Up
AuditPull
Fabric:
Additional Cloth Covers
Qty:
CM30G Recess with Gel Pad Insert - Naked Only
1 or 2 inch Depth:CM09 Sofspot - Std Foam
CM52 Extend Existing Shape
CM51 Square Pull
TFNP New Pan
QtyBKV Black VinylWWV Wedgewood Blue Vinyl
CM76S Additional Cover for Naked Cushion
SAV Sage Green Vinyl
$1,170.00CM01B Vinyl Upholstery (Non Removable)
PGV Purple Gray Vinyl
HWPMK78 Pan Mounting Kit - 7/8 inchBack Width: Back Height:HWWMK01 Wood Mounting Kit - 1 inch
inches
L-15 Teal Rubber Backed Lycra
$195.00
OCMK78 J & L Brackets-7/8 inch (railcut recommended)
OCMK01 J & L Brackets -1 inch (railcut recommended)
HWWMK78 Wood Mounting Kit - 7/8 inch$125.00
Lateral - Right
CM03 Untrimmed (vinyl only)
CM49 As Molded Show Placement on Cast/Image for These Modifications
CM49 As Molded
Lateral - Left
TAV Taupe Vinyl
$205.00$205.00$205.00
CM09P Duplicate Sofspot Pad (Vinyl Only)
CM52 Extend Existing Shape
1 or 2 inch Depth:
Depth:Qty:
$260.00HWABK Adjustable Back Moutning Hardware
Overlays only available on Naked Cushion
When opting for a 2- tone
fabric selection indicate "A" for contact surface,
"B" for non-contact
surfaces
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