Quickship Order Form - Helio wheelchair
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Transcript of Quickship Order Form - Helio wheelchair
519, J‐Oswald Forest, suite 101 Saint‐Roch‐de‐l'Achigan, QC, Canada J0K 3H0 T.450 588‐6555 1 866 650‐6555 F.450 588‐0200 www.motioncomposites.com November 14th, 2011
HELIO_CANADA_V0.10EN_QS
Page 1 of 2
Order Form | shipped within 72 hours
User manual: □ English □ French
Account : PO : Ship to :
Vendor : Name :
Date : Address :
Ordered by : City: Province :
Marked for : Postal Code : Phone :
1 Ultralight manual folding helio wheelchair1 WMA3QM005
/WAMC HELIO $2950 □
FRAME COLOR 2 Onyx black □ Sapphire blue □ NC □SEAT WIDTH & DEPTH 3 Seat width 16” □ 18” □ NC □4 Seat width 20” □ WAMA HSW1 $285 □ 5 Seat depth 16” □ 18” □ NC □6 Seat depth 20” □ WAMB HSD1 $215 □1 Maximum weight limit: 250lbs
BACK CANE, include push handles7 Lightweight carbon fiber straight back cane NC □ 8 Aluminum 8° bend back cane HBA1 $80 □ 9 Select height: 15” – 18” □ 18” – 21” □ Set height to : _____________ (measured from seat sling to top of back upholstery)
SEATING UPHOLSTERY 10 Nylon seat sling NC □BACK UPHOLSTERY 11 Slip on back upholstery NC □12 Adjustable tension back upholstery WAMD/WAME HBU1 $162 □ 13 Omit back upholstery HBU2 $‐15 □ FLIP BACK ARMREST 14 Full length, height 9½” – 12” HAR2 $348 □ FOOTREST 15 60° swing away footrest, 14” – 18” length adjustable HFR1 $55 □ 16 70° swing away footrest, 14” – 18” length adjustable NC □ Set length to :_______________
FOOTPLATES 17 Standard (Composite) NC □ 18 Adjustable angle oversize (Aluminum) WAMJ HFP1 $138 □19 One piece adjustable angle flip‐up HFP2 $190 □20 Length adjustable heel loop NC □
For the full feature Helio order form, please visit www.motioncomposites.com
519, J‐Oswald Forest, suite 101 Saint‐Roch‐de‐l'Achigan, QC, Canada J0K 3H0 T.450 588‐6555 1 866 650‐6555 F.450 588‐0200 www.motioncomposites.com November 14th, 2011
HELIO_CANADA_V0.10EN_QS
Page 2 of 2
CASTERS 21 Composite wheel /w PU tire (1’’ width) 5” □ 6“ □ NC □22
Composite wheel Soft‐Roll® by Frog Legs1
4” x 1 ½” HCA2 $85 □23 5” x 1 ½” HCA3 $95 □24 6” x 1 ½” HCA4 $105 □1 Soft‐Roll® by Frog Legs are casters that absorb vibrations
4” caster 5” caster 6” caster
Forks Stem bolt length Stem bolt length Stem bolt lengthSTD +1” +2” STD +1” +2” STD +1” +2”
4” P1 14 ½ 15 ½ 16 ½ P2 15 16 17 15 ½ 16 ½ 17 ½
5”
P1 P2 15 ¼ 16 ¼ 17 ¼ 15 ¾ 16 ¾ 17 ¾ P3 15 ¾ 16 ¾ 17 ¾ 16 ¼ 17 ¼ 18 ¼ 16 ¾ 17 ¾ 18 ¾ P4 16 ¼ 17 ¼ 18 ¼ 16 ¾ 17 ¾ 18 ¾ 17 ¼ 18 ¼ 19 ¼
7”
P1 17 ¼ 18 ¼ 19 ¼ P2 17 ¼ 18 ¼ 19 ½ 17 ¾ 18 ¾ 19 ¾ P3 17 ¾ 18 ¾ 19 ¾ 18 ¼ 19 ¼ 20 ¼ P4 17 ¾ 18 ¾ 19 ¾ 18 ¼ 19 ¼ 20 ¼ 18 ¾ 19 ¾ 20 ¾ P5 18 ¼ 19 ¼ 20 ¼ 18 ¾ 19 ¾ 20 ¾ 19 ¼ 20 ¼ 21 ¼
REAR WHEELS, include quick release axle 25 Spoke 22” □ 24” □ WAMU NC □26 Spinergy Wire® 22” □ 24” □ WAMU HRW2 $275 □ TIRES 27 Soft urethane 1 ⅜” 22” □ 24” □ NC □28 Pneumatic 1 ⅜” 22” □ 24” □ NC □
HANDRIM 29 Aluminum anodized Assembly
regular □ narrow □ NC □
30 Plastic coated WAMO HHR1 $130 □
REAR WHEEL CAMBER ANGLE 31 0° camber NC □ 32 3° camber NC □
WHEEL LOCK 33 Push to lock □ Pull to lock □ NC □34 6” removable extension handle HWL1 $32 □
POSITIONING BELT 35 Auto buckle HPB2 $40 □ 36 Hardware for 4 points seatbelts HPB3 $16 □
ACCESSORIES 37 Anti tippers HAC1 $75 □38 Cane Carrier left □ right □ HAC2 $85 □
Transit securement points come standard on every Helio wheelchair
Total
Wheel size Height available ± ¼” 22” wheel 13 ½” to 18”24” wheel 14 ½” to 19”
Specify desired height: __________
REAR SEAT‐TO‐FLOOR HEIGHT
FRONT SEAT‐TO‐FLOOR HEIGHT MATRIX
Circle the desired configuration