Quickie QM-715 HD Order Form (Rev. G)

Account:

Date:

PO#:

Buyer:

Marked For:

Quickie QM-715™ HD Group 3

(K0848, K0856, K0861)

EIPW11, November 2013

SUBMIT

Ship To:

Name:

Address:

City,State,Zip:

Phone:

D Option # HCPCS

The HCPCS CODES provided are based on code verification through PDAC or our interpretation of the code definitions.

The use of HCPCS CODES does not ensure coverage or payment. For coverage information, verify the appropriate payer's coverage policy.

Definition Price D Option # HCPCS Definition

1. QUICKIE QM-715™ HD GROUP 3 CATEGORY (Select One)

Price

172PC79

QUICKIE QM-715™ HD BC (Group 3 K0850/K0011)

Quickie QM-715™ HD BC w/ ASAP II Seat (Fig 1.1)

K0850

K0011

Base Package

VR-2 90A Drive Control (non-expandable)

400 lb 5 mph 4-pole Motor Package

ASAP II Rehab Seat Frame

14" Drive Wheels (flat free insert N/C)

8A Dual Mode (Compact) CTE

172NB88 K0850

QM-715™ HD BC BASE ONLY

For use with Aftermarket Seat frame.

172EQ19

172EQ18

-

-

QM-715™ HD BC SEAT ONLY w/o elect. For use to add/replace seating when additional electronics are not required.

QM-715™ HD BC SEAT ONLY w/ elect.

For use to add/replace seating when additional electronics are required.

$6,265.00

$6,265.00

$750.00

$750.00

172PC80

QUICKIE QM-715™ HD SC (Group 3 K0858/K0011)

Quickie QM-715™ HD SC for SPOT Tilt (Fig 1.2)

K0858

K0011

Base Package



ASAP II Rehab Seat Frame



172NB89 K0858

QM-715™ HD SC BASE ONLY

For use with Aftermarket Seat frame.

172EQ21 -

QM-715™ HD SC SEAT ONLY w/o elect

For use to add/replace seating when additional electronics are not required.

172EQ20 -

QM-715™ HD SC SEAT ONLY w/ elect.

For use to add/replace seating when additional electronics are required.

$6,695.00

$6,695.00

$750.00

$750.00

QUICKIE QM-715 ™ MPC (Group 3 K0862/K0011)

Quickie QM-715™ HD MPC SPOT Tilt/Recline (Fig. 1.3)

172PC104

K0862

K0011

Base Package



Recline Seat Frame



172NB102 K0862

QM-715™ HD MPC BASE ONLY

For use with Aftermarket Seat frame.

172EQ36 -

QM-715™ HD MPC SEAT ONLY w/ elect. For use to add/replace seating when additional electronics are required.

$6,695.00

$6,695.00

$6,695.00

$750.00

1.1 QM-715™ HD BC 1.2 QM-715™HD SC 1.3 QM-715™HD MPC

ORDERING INFORMATION: PHONE: (800) 333-4000 FAX: (800) 300-7502

E-MAIL: [email protected] WEBSITE: www.sunrisemedical.com

Specifications are subject to change without notice. Copyright © 2013 120756 REV G

Page 1

Speed Package

172PF84 -

Shroud Color

172EZ01

172EZ02

172EZ03

172EZ04

172EZ05

172EZ08

172EZ09

172EZ10

172EZ11

172EZ12

172EZ13

172EZ15

172EZ06

172EZ07

172EZ14

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

User weight

172WG03

172WG13

172WG14

-

-

-

400lbs / 5 mph 4 Pole Motor

Candy Apple Red

High Gloss Black

Candy Blue

Silver

Copper

Green Apple

Yellow

Pearl Pink

Candy Purple

Matte Black

Midnight Blue

Pearl White

Digital Camo.

Woodland Camo.

Carbon Fiber Print

2. BASE CHAIR OPTIONS

N/C

Drive Wheel

172DW36 -

172DW37

172DW59

N/C

$500.00

$500.00

$500.00

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C

N/C Wheel locks

172WL42 -

-

-

14" Cast Wheel Pneumatics

Grey Knobby Tires and Grey Casters

14" Cast Wheel Solid Dual Density Inserts

Grey Knobby Tires and Grey Casters

14" Cast Wheel Solid Dual Density Inserts

Black Knobby Tires and Black Casters

Wheel locks

Ventilator Options

172VT4 E1029

Fixed Vent Tray (Pulmonetic LTV Models)

N/C

N/C

N/C

$100.00

$440.00

Pre-Set Seat Frame Angle (STFH increases 1" per increment change)

172FA10 0°

172FA3

172FA4

-

-

N/C

3° N/C

Not available with Tilt

6° N/C

251-300lb

301-350lb

351-400lb (NA with Power Recline)

Seating Type and

Power Option Combinations

BC ASAP II No power seating.*

SC ASAP II HD Tilt only

SC Power Recline Only Seat *

MPC HD Tilt and Power Recline seating.

N/C

N/C

N/C

Seat Height (Use STFH Matrix below)

(Measured in the front) - Obtain Quote to verify est. STFH

172HT44

172HT49

172HT45

172HT46

172HT47

172HT48

-

-

-

-

-

-

Lowest STFH

+.5" STFH

+1" STFH

+2" STFH

+3" STFH

+4" STFH

Requires Group 34 Batteries

STFH Matrix

Low

16.3

16.8

+.5"

16.8

Seat-to-Floor Height at 0 tilt

+1" +2"

17.3

18.3

+3"

19.3

17.3

17.8

16.1

16.5

18.8

17.1

17.5

19.8

18.1

18.5

+4"

20.3

20.8

19.1

19.5

*Adding seat angle will increase STFH by 1" for each incremental change.

STFH measured with batteries but no user. Actual STFH may vary by .5"

N/C

N/C

N/C

N/C

N/C

N/C

Batteries (Gel Cells)

172AG04

172AG11

172AG13

E2363

E2359

-

Group 24 Flat Top Gel Cell (Pair) w/straps

Recommended for Maximum Daily Range

Group 34 Flat Top Gel Cell (Pair) w/straps,

Required for lower STFH.

Omit batteries Ready for Group 24 or 34 Includes harness and straps.

3. BATTERIES and CHARGERS

$710.00

$690.00

N/C

Battery Charger

172BJ19

172BJ3

-

-


Omit Charger

N/C

-$40.00




Page 2

Drive Control Options

172ER01 Non-expandable controller

 R-Net Expandable Drive Control Upgrade (90A)

172EX01

172EX02

E2377

E2313

Expandable Controller - R-net

Harnessing for Expandable Controller

VR2 Joystick (non-expandable)

172J94 Non Expandable VR2 Joystick

R-net Joystick (for expandable electronics)

172J70 Std LED Joystick for Expandable Ctrls

172J108 Joystick w/Stereo Jacks & Color Display

172J88

172J95

-

-

Joystick W/Toggle, Spd Pot, Stereo Jacks &

Color Display

Omit JS for use with OMNI

Joystick Mount (Fixed or Swing Away)

172JM10 Fixed Mount

172JM11 E1028 Swing Away Mount

Joystick Mount (Location)

172HM1

172HM2

-

-

Height Adjustable.

Right Side Mount

Left Side Mount

Joystick Handle (Optional)

172JH1 E2323 Ball Handle

172JH2

172JH4

172JH6

E2323

E2323

E2323

Foam Ball Handle

T-Handle

Goalpost

R-net OMNI and Output Options

(For expandable controls, choose all that apply)

172ON1

172ON2

172ON3

-

E2351

-

Rnet OMNI Input Control Module and display with built in Infrared and armrest mount. Choose mount below. (required for Specialty Input

Devices.)

Rnet Output Module (ECM)

Rnet Bluetooth Mouse-mover

OMNI Mount

172DS03

172DS04

(If used with Joystick must be mounted opposite side)

E1028 Swing Away Left Side OMNI Mount

E1028 Swing Away Right Side OMNI Mount

Switch inputs for Joysticks or OMNI

Drive or Mode / Profile Control

172SW22

172SW6

172SW1

172SW2

172SW9

172SW4

172SW24

172SW21

Ribbon Switch

Buddy Button Switch

Disc Switch

Wobble Switch

Micro Light Switch

Egg Switch-Black

Dual toggle switch only

172SW23 4-way toggle switch w/5th button DB9 Connector.

4. ELECTRONICS

N/C

$950.00

$525.00

$425.00

Switch Mount Bracket

172EM01 Single Switch Mount Bracket

172EM02

172EM03

Dual toggle switch mount bracket

4-way toggle switch mount bracket.

$195.00

$195.00

$195.00

N/C

N/C

$200.00

$395.00

N/C

N/C

$235.00

N/C

N/C

$75.00

$75.00

$75.00

$75.00

$975.00

$995.00

$850.00

$235.00

$235.00

$95.00

$75.00

$160.00

$500.00

$75.00

$95.00

$170.00

$170.00

Specialty Driver Control Options

Requires expandable controls and OMNI. Not available with Upholstered backs.

Quickie Sip n' Puff System

172ID34

172II01

E2325

E0955

Sip N' Puff Kit

Headrest

172IJ01

172IH1

E1028

E2326

Headrest Removable Mount

Sip n' Puff Tubing and Hardware

ASL Head Array Package (Adult)

172II02 E2330 ASL Proximity Head Array (Adult)

172IJ01 E1028 Headrest Removable Mount

ASL Head Array Package (Ped)

172II03 E2330 ASL Proximity Head Array (Ped)


Switch-It Head Array Package (Adult)

172II04 E2330 Switch-it Proximity Head Array


Switch-It Head Array Package (Pediatric)

172II05 E2330 Switch-it Proximity Head Array


ASL Proportional Mini Joystick

Chin / Lip Control Package

172ID36

172II01

172IJ01

E2312

E0955

E1028

Mini Joystick

Headrest

Headrest Removable Mount

ASL Proportional Mini Joystick

Midline with Gatlin Package

172ID37

172IJ03

E2312

E1028

Mini joystick

S/A Joystick Mount

Quickie Proportional Chin Control Package

172ID45 E2312 Proportional Joystick

172IJ03 E1028 S/A Joystick Mount

$2,234.00

$1,420.00

$225.00

$225.00

$364.00

$4,020.00

$3,795.00

$225.00

$4,020.00

$3,795.00

$225.00

$4,020.00

$3,795.00

$225.00

$4,020.00

$3,795.00

$225.00

$4,945.00

$4,495.00

$225.00

$225.00

$4,720.00

$4,495.00

$225.00

$4,345.00

$4,120.00

$225.00

Attendant Control

1720A01 E2331

1720A02 E2331

Attendant Control for VR-2

Attendant Control for R-net

$995.00

$995.00

Attendant Mounting location

172DN1

172DN2

Mounting location: Right Back Cane

Mounting Location: Left Back Cane

Electronic Programmers

172PR2 VR-2 Hand Held Programmer

172PR5 R-net PC Programmer with Dongle

172PR6 DTT VR2 and Rnet cables included.

N/C

N/C

$250.00

$400.00

$1,000.00




Page 3

172ST56 -

Quickie A.S.A.P II

(Adjustable Seating and Positioning) Choose

Seat Frame Size Platform.

ASAP II Frame size

(each frame is width and depth adjustable within given range. )

172FU18 Adjustable 16x12 to 20x20 ( B )

172FU19 -

Adjustable 18x16 to 22x22 ( C )

Note: Choose this seat when selecting the

Fixed 24" wide B4me option ( D )

5. SEAT TYPE

N/C

172ST57 -

Power Recline (requires Expandable Rnet electronics)

Recline Seat Frame size

N/C

N/C

172FU27 -

Power Recline Seat Frame ( H )

18x18 to 22"x22" (Not width Adjustable)

N/C

N/C

6. SEAT SIZE

B = ASAP II Seat Frame

(Adjustable from 16X16 to 20X20)

C = ASAP II Seat Frame

(Adjustable from 18X16 to 22X22)

Seat Size Matrix.

Seat type is chosen in section 5.

16"

17"

18"

19"

20"

21"

22"

ASAP II Seat Width

16" 17" 18" 19" 20" 22" 24"

B

B

B B,C B,C B,C C

B B,C B,C B,C C

D

D

B

B

B

B B,C B,C B,C C

B B,C B,C B,C C

B B,C B,C B,C C

C

C

C

C

C

C

C

C

D

D

D

D

D

D = Fixed Seat Frame 24"

(Depth Adjustable 16 to 22)

Seat Width

172R5

172R6

172R7

172R8

172R9

172R25

16"

17"

18"

19"

20"

22"

Seat width

Seat width

Seat width

Seat width

Seat width

Seat width

Seat Width Built-4-Me

172VU16 E2202 24"

Seat width (fixed width, depth is adjustable

16" to 22" deep)

N/A with Power or manual recline back or sling back upholstery.

(N/C)

(N/C)

(N/C)

(N/C)

(N/C)

(N/C)

$450.00

Seat Depth

172RF5

172RF6

172RF7

172RF8

172RF24

172RF26

172RF25

Recline Seat Width

H = HD Recline Seat

(Width not adjustable)

18"

19"

20"

21"

22"

18" 20" 22"

H

H

H

H

H

H

H

H

H

H

H

H

H

H

H

Note: Power Recline Seat Depth measured from solid surface of back to front of seat pan. Please accommodate for backrest cushion thickness.

16"

17"

18"

19"

20"

21"

22"

Seat depth

Seat depth

Seat depth

Seat depth

Seat depth

Seat depth

Seat depth

(N/C)

(N/C)

(N/C)

(N/C)

(N/C)

(N/C)

(N/C)

Standard Cushion

172CU1 2" Cushion

Power Seating Options (SC and MPC Models)

172PJ2 E1002

Quickie HD SPOT 50° CG Tilt

(400lbs weight limit)

172PA16

172PA17

E1005

E1008

HD Recline w/Power Shear Reduction Only

(350lbs weight limit)

HD Tilt & Recline w/Power Shear Reduction

(350 weight limit)

Powered Seating Control Method

(For use with power seating actuators. Switch activation is stand-alone and does not require expandable or thru-drive electronics.

172EO10

172EO11

172EO12

Switch Control 1 actuator w/dual toggle and mount. (For operating Tilt)

Switch Control 1 actuator w/buddy button & mount. (For operating Tilt)

Switch Control 2 - 3 Actuator w/ 4-way Toggle

Switch & Mount. (Capable of operating combo of

Tilt/Legs or legs only)

N/C

N/C

N/C

Switch Mount

172EY01

172EY02

-

-

(for use with switch control powered seating)

Switch Mount Right

Switch Mount Left

N/C

N/C

7. SEAT CUSHIONS

JAY Cushions (Optional)

To order any JAY cushions on-chair, please see the JAY price list.

$95.00

Cushion name or part number must be filled out w/ desired width and depth

JAY Bundled Cushion

172JC20 Cushion Name or Part #

Width: Depth:

8. POWERED SEATING

Powered Seating Thru-drive Control Method.

$4,950.00

$6,225.00

$10,495.00

Price List

"Assignable Button" feature listed below (available on Rnet Systems) allows for direct "short-cut" access to various seating functions via joystick buttons. Functions accessed by depressing the button for more than 1 second. By selecting the thru-drive w/assignable button the chair will be preprogrammed with seating functions assigned to buttons on the joystick. Assignments can be changed via PC Dongle.

172EO15

172EO13

E2310

E2310

Thru-Drive 1 Actuator options.

Thru Drive 1 Actuator w/out assignable buttons.

For use with VR2 or R-net

(For operating Tilt thru Joystick.)

Thru Drive 1 Actuator with assignable buttons.

(For operating Tilt thru Joystick and/or buttons on the remote. Requires R-net.)

172EO16

172EO14

E2311

E2311

Thru-Drive 2+ Actuator options.

Thru Drive 2+ Actuators w/out assignable buttons

(For operating Tilt, Recline or Power Legs thru

Joystick requires expandable Rnet)

Thru Drive 2+ Actuators with assignable buttons.

(For operating Tilt, Recline or Power Legs thru

Joystick and/or buttons on the remote. Requires expandable Rnet)

$1,375.00

$1,375.00

$2,825.00

$2,825.00




Page 4

9. BACKREST AND BACK OPTIONS for ASAP II (BC and SC)

Backrest Frame Type

172BT8 Angle Adjustable (ASAP II Seat only) N/C

Back Type (Uphostery or Solid)

172BU1 Upholstery (Not avail with tilt or recline)

172BT98 E1225

Manual Recline 40° (ASAP II Seat only) not width adjustable

$425.00

172BU70 E2611

Tension adj Upholstery Ballistic Nylon. (with 1" width adjustment.) (Not avail with tilt or recline)

N/C

$315.00

Manual Recline Adjustment Method Option

Back Cane Height 23".

172MN01 Tool

172MN02 Knob (NA with Cantilever or dual post arms.)

Angle Adjustable Backrest Options

(NA with Manual recline)

172OD8

172OD9

Cane Angle

172BP40

Non-Folding Backrest

Folding Backrest

172BP41

Straight Back Post

8 o

Bend Back Post (Avail. only w/ Upholstery or

J3 Back)

Towel Bar Depth

172QT03 Shallow (NA with Upholstery backs.)

172QT04

Deep (Extends 4" from back canes for deep backs)

Back Cane

(Upholstery Height Measured pan to top of upholstery.)

Low (15.5") 172B1

Med (17.5")172B5

Tall (19.5") 172B9

N/C

N/C

N/C

$110.00

N/C

$100.00

N/C

N/C

172BU71

172BU76

172BU77

172BU78

E2611

-

E2613

E2617

Tension adj Upholstery 3DX Vented.

(with 1" width adjustment) (Not avail with tilt or recline)

S.P.O.T. Curved

Jay SPO Posterior Positioning

(ASAP II only)

ART SPO Custom Back

(ASAP II only) See appendix 1

$330.00

N/C

$475.00

See Pg 8

172BU14 Omit Back.

Jay 3 Option

172JB01 Jay J3 for ASAP II (select OMIT above)

Back Height - Required for SPOT Curved, SPO Backs.

(Limited combinations of widths) Measured from pan to top of solid back.

172B132 14"

172B36 16"

172B38 18"

172B40

172B42

-

-

20"

22"

172B44

172B140

-

-

24"

26"

-$15.00

See J3 OF

N/C

N/C

N/C

N/C

N/C

N/C

N/C

10. BACKREST AND BACK OPTIONS for 3.7 POWER RECLINE (MPC)

Backrest Frame Type

172BT89 Power Recline (Power Recline Seat only) N/C

Back Height - Required for Standard Curved Recline Backs and Jay 3 recline backs.

Power Recline Backrest Preset Home Angle N/C

90° 172QK1

172BU83

172JB03

-

-

Back Type (Solid Recline)

95° 172QK2 default

100° 172QK3

Standard Curve back with 1.5" Foam cushion.

(Reduces Seat Depth)

Jay J3 for Power Recline w/1.5" Foam

Choose type below. (Reduces Seat Depth)

N/C

N/C

172B42

(Limited combinations of widths) Measured from pan to top of solid back.

22"

Avail w/ standard curved and

Jay3 MT (PA/PL backs)

172B44 24"

172B140 -

26"

172B141 -

27"

172B142 -

Push Handle Options

28"

172BP55 -

Fixed "Cane" Handles.

172BP56 -

Height Adjustable Push Handles.

w/2 utility hooks

N/C

N/C

N/C

N/C

N/C

N/C

$50.00

172BU84 $350.00

172BP57 Omit push handles N/C

Jay 3 Contour.

172JP01 E2613

172JP02

172JP03

172JP04

172JP05

E2614

E2615

E2620

E2620

JAY 3 BACK for 3.7 POWER RECLINE OPTIONS

POSTERIOR [PA] E2613 - E2614

J3 PA Back (2.2" of Contour Depth)

Available 14"-20" Wide (J3PAUTZYYXX)

J3 PA Back (2.2" of Contour Depth)

Available 22" Wide (J3PAUTZ22FX)

J3 PL Back (3.0" of Contour Depth)

Available 14"-20" Wide (J3PLUTZYYXX)

J3 PDL Back (6.0" of Contour Depth)

Available 14"-20" Wide (J3PDLUTZYYXX)

J3 PDC Back (6.0" of Contour Depth)

Available 14"-20" Wide (J3PDCUTZYYXX)

$535.00

$795.00

$620.00

$745.00

$745.00

POST & LATERAL [PL] E2615

POSTERIOR & DEEP LATERAL [PDL] E2620 POSTERIOR & DEEP CONTOUR [PDC] E2620

Jay 3 Back Height. Backs are height adjustable

172JR06

172JR01

172JR02

172JR03

172JR04

-

-

-

-

-

MT for 22" tall back.

(Mid Thoracic Short 15" shell)

UT for 24" tall back.

(Upper Thoracic Short 16.5" shell)

UT for 26" tall back.

(Upper Thoracic Med 18" shell)

UT fot 27" tall back.

(Upper Thoracic Tall 19.5" shell)

SH for 28" tall back and widths 14-20"

(Shoulder Height 21" shell, )

172JR05 -

SH for 26-28" tall back and 22" wide seat

(Shoulder Height 18" shell, )

SPINE-ALIGN MINI FIT KIT 2

Includes: 5 wedges, 2 lat shims, 2 post/lat pelvic, 1 lg lumbar, 1 flat shim, and 1 curved

172JS01 K0108 SPINE-ALIGN MINI FIT KIT 2

N/C

N/C

N/C

N/C

N/C

N/C

$101.00

Jay 3 Width

Back can be ordered 2" narrower than seat pan. Armrest will be adjusted to back width ordered.

Future growth can be accomplised by replacing back with wider versions and adjusting arms outward.

172JQ01

172JQ02

-

-

Back width 14" (Use w/ 14-16" wide seat)


N/C

N/C

172JQ03

172JQ04

172JQ05

-

-

-


Back width 20" (Use w/ 20-22" wide seat

Back width 22" (Use with 22" wide seat)

N/C

N/C

N/C




Page 5

Headrest Mount

172MH10 E1028

172MH11 E1028

172MH1 E1028

Axys Mount & Bracket

Cobra Mount and Bracket

Linx Mount and Bracket

11. HEADREST OPTIONS

Choose One Each.

Headrest Pad

$220.00

172HE65 E0955

$280.00

172HE66 E0955

$225.00

172HE78 E0955

Plush Head Support Pad 8"



$225.00

$225.00

$225.00

LATERAL THORACIC SUPPORT (Swing Away)

Available on all Solid Backs.

LAT 4X4 S/A MOUNTS W/ 1" OFFSET - PR

172ZV14 E0956 LATERAL 4X4 W/ 1" OFFSET - PAIR

172ZS07 E1028 LATERAL SWING AWAY MOUNT - PAIR


172ZV15 E0956 LATERAL 4X5 W/ 1" OFFSET - PAIR

172ZS07 E1028 LATERAL SWING AWAY MOUNT - PAIR


172ZV16

E0956 LATERAL 4X6 W/ 1" OFFSET - PAIR

172ZS07

E1028 LATERAL SWING AWAY MOUNT - PAIR


172ZV17


172ZS07



172ZV18

172ZS07

E0956

E1028

LATERAL 6X5 W/ 1" OFFSET - PAIR

LATERAL SWING AWAY MOUNT - PAIR


172ZV19

172ZS07



CHEST STRAP

172ZR03 E0960 Padded Chest Strap

$778.00

$251.00

$527.00

$778.00

$251.00

$527.00

$778.00

$251.00

$527.00

$778.00

$251.00

$527.00

$778.00

$251.00

$527.00

$778.00

$251.00

$527.00

12. POSTURAL SUPPORTS

$225.00

Swing Away Knee Adductor Supports

Available only with Fixed and Power Center Mount Legrests.

Not available with Dual Post Arm Rests or 2-point Locking Cantilever Arms

Knee Adductor Supports - LEFT (choose Pad and Arm)

Pad Size

172KB5 E0956 Knee Adductor Pad SM- Left

172KB7 E0956 Knee Adductor Pad LG- Left

S/A Arm Size

172XX04 E1028 Swing Away Short - Left

172XX06

E1028 Swing Away Long - Left

Knee Adductor Supports - RIGHT (choose Pad and Arm)

172KB6

172KB8

Pad Size

E0956 Knee Adductor Pad SM- Right

172XX05

172XX07

E0956 Knee Adductor Pad LG- Right

S/A Arm Size

E1028 Swing Away Short - Right

E1028 Swing Away Long - Right

$395.00

$170.00

$170.00

$225.00

$225.00

$395.00

$170.00

$170.00

$225.00

$225.00

Long Thigh Support w/Removable Mount

Available with Cantilever Arms, NA with Manual Recline Back, Dual Post, Single Post or Cantilever w/ 2 pt Locking arms.

SPOT Long Thigh Support - Left $325.00

172TV2 E0956 Long Thigh Support - Left

172TX1 E1028 Removable Mount - Left

SPOT Long Thigh Support - Right

172TV1

E0956 Long Thigh Support - Right

172TX2

E1028 Removable Mount - Right

$100.00

$225.00

$325.00

$100.00

$225.00




Page 6

13. ARMREST AND ARMPAD OPTIONS

13A. Armrest options for ASAP II seating.

Armrest Mounting for K0848 BC Models with ASAP II

Dual Post Armrests

172EG01 Short Dual Post Flip Back 10" Height.

172EG21

172EG02

Long Dual Post Flip Back 10" Height.

E0973 Shrt Dual Post Flip Back HT Adj 10"-15"

172EG22 E0973 Lng Dual Post Flip Back HT Adj 10"-15"

Cantilever Armrests

N/C

N/C

$230.00

$230.00

(Adjustable length arm pad included (choose Pad setting below, except for Low Arm Option) NA with

Manual Recline Back

172EG03 E0973

Standard Cantilever Arm w/ 2 Point Locking

Post. (9"-10" Ht Range.) NA w/ seat depths below 16"

$230.00

172EG04 E0973



172EG05 E0973 STD Cantilever Arm 9"-12" Ht Range

172EG06 E0973

Low Cantilever Arm 7"-10" Ht Range (Choose

ASAPII pad type and size below)

Single Post Armrests

172EG07 E0973 Single Post Height Adjustable - Std.

172EG08 E0973 Single Post Height Adjustable - Low

$230.00

$230.00

$230.00

$230.00

$230.00

Armrest Mounting for K0856 SC Models with ASAP II.

Dual Post Armrests

172EG09 Shrt Dual Post Flip Back HT Adj 10"-15"

172EG23 Lng Dual Post Flip Back HT Adj 10"-15"

N/C

N/C

Cantilever Armrests

(Adjustable length arm pad included (choose Pad setting below, except for Low Arm Option) NA with

Manual Recline Back

172EG10 -



N/C

172EG11 -



172EG12 STD Cantilever Arm 9"-12" Ht Range

172EG13 -

Low Cantilever Arm 7"-10" Ht Range (Choose

ASAPII pad type and size below)

Single Post Armrests

172EG14 Single Post Height Adjustable - Std.

172EG15 Single Post Height Adjustable - Low

N/C

N/C

N/C

N/C

N/C

Armpad Options for ASAPII

Pad Type / Size Options for Dual Post / Single Post / Low Cantilever

Left Arm Pad (N/C)

172AE01 -

Right Arm Pad (N/C)

172AB01

172AE02

172AE03

172AE04

-

-

-

Desk Length Waterfall (10")

Full Length Waterfall (14")

NA w/Low Cantilever arm

Desk Length Standard (10")

Full Length Standard (14")

NA w/Low Cantilever arm

172AB02

172AB03

172AB04

Left Arm Pad (N/C)

172AE11

172AE10

Pad Setting Options for Standard Cantilever Arm

-

-

Full Length Cantilever (14")

Desk Length Cantilever (10")

Right Arm Pad (N/C)

172AB11

172AB10

172EG26

172EG27

172EG28

-

-

13B. Armrest options for Power Recline Seating

Armrest for Power Recline Seating.

(Armrest width can be adjusted 2" narrower than seat)

-

STD Cantilever/Reclining Arm 10-14" Height

Range

Cantilever/Reclining Arm w/ 2 Point Locking

Post. (10"-12" Ht Range.)

Cantilever/Reclining Arm w/ 2 Point Locking

Post. (12"-14" Ht Range.)

N/C

$230.00

$230.00

Reclining Armpad Options

(Armpad can be angled inward 15 degrees)

Standard Reclining Armpad

Left Arm Pad (N/C) Right Armpad (N/C)

172AE05 Reclining Arm Pad (16")

172AB05

Otto Bock Reclining Armpad (Power Recline Seat only)

Left Arm Pad ($120.00) Right Armpad ($120.00)

172AE08

172AE06

172AE07

E2209 SM Forearm Pads (8")

E2209 MD Forearm Pads (11.5")

E2209 LG Forearm Pads (14")

172AB08

172AB06

172AB07

Otto Bock Hand Pad Options

Left Hand Pad ($52.50) Right Hand Pad ($52.50)

172OL01 MD Flat Hand Pads (4-1/2" x 7") 172OR01

172OL02 LG Flat Hand Pads (5-1/2" x 9") 172OR02




Page 7

14. HANGERS AND FOOTRESTS FOR ASAP II

Non-Powered Swing Away Legrests

Sold as Pairs

Hanger and Extension Tubes Options (see footplate compatibility in the brackets)

Footplate (Pair)

 A - Composite with Heel Loop (Pair)

172H95

172H2

172H94

172H6

65° Swing Away (A,B,C)

70° Swing Away (A,B,C)

75° Tapered Swing Away (E)

90° Swing Away (B,C) (5.5-9")

N/C

N/C

N/C

N/C

172F1

172HL1 E0951

Composite Footplate

Heel Loop

B - Adult Angle Adjust w/Heel Loop for use with 65°, 70° hanger and ELR (Pair)

172H138 E0990

Manual ELR S/A (A,B,C,D) (Avail. with Fixed

Centermount, choose below)

$270.00

172F282

172HL10

K0040

E0951

Adult Angle Adjustable Footplate

Heel Loop

Powered Elevating Legrests

B - Adult Angle Adjust w/Heel Loop for use with 90° hanger (Pair)

172H125 K0108

Power Centermount ELR w/ Articulation (Leg

length indepedant actuator for transfer assist) (F)

$2,200.00

172F285 K0040 Adult Angle Adjustable Footplate

172H126 E1010

Fixed Center Mount Legrests (includes footplate) N/C

 172H134 Fixed Center Mount Short

 172H135 Fixed Center Mount Long

Omit Hangers.

172H144

S/A Power ELR w/ Articulation (B) Pair

(N/A for 12" or 13" wide) (Avail. with Fixed

Centermount, choose below)

Omit Hangers

Hanger Extensions. (See range listed in matrix below)

$2,200.00

N/C

NOTE: Not all extension tube will be available; depending on the seat height, some extension tube options may not offer enough ground clearance.

172E16

172E1

172E2

172E5

172E21

K0037 High Mount Hanger

Short

Medium

Long

Omit Extension

N/C

N/C

$55.00

N/C

N/C

N/C

N/C

172HL10

172F283

172LS13

E0951 Heel Loop

C - Kids Angle Adjust w/Leg Strap for use with 65° and

70° hanger (Pair)

K0040

K0038

Kids Angle Adjustable Footplate

Leg Strap

C - Kids Angle Adjust w/Leg Strap for use with 90° hanger(Pair)

172F286 K0040 Kids Angle Adjustable Footplate

172LS13 K0038 Leg Strap

172F287 D - Aluminum (Pair)

E - One Piece Angle Adjust Footplate

172F284

172LS13

K0040

K0038

One piece Angle Adjustable Footplate

Leg Strap

172F315

172F279

F - Centermount Single/Dual Footplate

(Single Footplate can be unlocked to form individual footplates)

K0040 CMT Angle Adjustable Footplates

Omit Footplate and extension tube

Footrest Accessories

1725A01 E0952 Toe Loop (Pair) Only avail on (opt B).

172LS14 K0038 Extra Leg Strap

Hanger Type

Lower Leg Length Matrix

(measured seat pan to the top of the footplate surface)

High Mount Short Medium

65° Swing Away

70° Swing Away

75° Tapered S/A

90° Swing Away

Manual ELR S/A

Power ELR S/A

Fixed Cntrmnt

Power Cntrmnt

7-14"

7-14"

7-14"

Long

13.5- 16"

13.5- 16"

13.5- 16"

16-18.5"

16-18.5"

14.5-19"

5.5-9" Footplate mounts to front of hanger.

12.5-17"

12-14"

12.5"-15.5"

14.5-19"

14-17"

18-20.5"

18-20.5"

15-18"

17-21"

16.5-19"

14.5"-19.5"

14"-18"

Hanger Type

65° Swing Away

70° Swing Away

75° Tapered S/A

90° Swing Away

Manual ELR S/A

Power ELR S/A

Fixed Cntrmnt

Power Cntrmnt

Footplate Matrix

X

A

X

X

B

X

X

X

X

X

C

X

X

X

X

D

X

E

X

Single Ftplate included

F

X

Wheelchair Tray Table

NA with Otto Bock Armrest.

1727A01 E0950 TRAY TABLE SM TUFFAK 13-14

1727A02

1727A03

E0950 TRAY TABLE MED TUFFAK 15-17 PWR

E0950 TRAY TABLE LRG TUFFAK 18 PWR

Backpack

172A1

172A2

Black Utility

Black/Charcoal Kids

14. ACCESSORIES

$225.00

$225.00

$225.00

Positioning Belt - Select for any style seat

172EJ01 Auto Style Buckle

172EJ02 E0978 Belt 2" Aircraft Buckle

172EJ03 E0978 Belt 2" Aircraft Buckle Padded

BUILT 4 ME OPTIONS

To Inquire about any unique customization for Quickie products, contact:

Phone: (800) 333-4000, Option #3 or Fax: (800) 333-9011

$55.00

$50.00

$165.00

$45.00

$195.00

$165.00

$30.00

$195.00

$165.00

$30.00

$30.00

$195.00

$165.00

$30.00

$30.00

N/C

$30.00

$210.00

$165.00

$45.00

$210.00

$165.00

$165.00

N/C

$45.00

$30.00

N/C

$35.00

$65.00




Page 8

Account:

Date:

PO#:

Buyer:

Marked For:

1. Backrest Type

SPO E2617 CUSTOM Rectangular Back (Dia / Fig. A)

CUSTOM 172GI01 Complete only Dimensions A & B below

Foam components similar to Diagram D

SPO

I-Back

E2617 I-Shape Back (Diag./ Fig. B)

172GI02 Complete Dimensions A - E Below


ART SPO CUSTOM CURVED BACKREST

Posterior Positioning Backrest (E2617)


Ship To:

Name:

Address:

City,State,Zip:

Phone:

$895.00

$995.00

DIAGRAM A DIAGRAM B

Figure A - Custom Rectangular Back Figure B - I Shape Back

BACK REST TYPE DIMENSIONS

14

14.5

15

15.5

16

16.5

17

17.5

18

18.5

19

19.5

20

20.5

21

21.5

22

22.5

23

23.5

24

24.5

25

25.5

26

26.5

27

27.5

28

Dimension A

BACK HEIGHT

Dimension B

BACK WIDTH

(must be same as Base Width)

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

16 17 18 19 20

3

3.5

3

3.5

4

4

4

4.5

5

5.5

3

3.5

4

4.5

5

5.5

3

3.5

6

7

7

8

8

9

9

10

10

11

11

7

8

8

9

9

4.5

4.5

5

5.5

6

3.5

4

3.5

4

3.5

4

4.5

10

10

11

11

Dimension C

I-BACK ONLY

5

5

5.5

6

7

8

9

9

10

10

4

4.5

4

4.5

4

4.5

5

11

5

4.5

5

5.5

5.5

5.5

6

7

8

9

10

5.5

5

5.5

6

6

6

7

8

Dimension D

I-BACK ONLY

5

5

5

5

5

5

5 6 7

5 6 7

5 6 7 8

5 6 7

5 6 7 8

5 6 7 8

5 6 7 8

5 6 7 8

7 5 6 7 8

5 6 7 8

5 6 7 8

5 6 7 8

5 6 7 8

5 6 7 8

5 6 7 8

5 6 7 8

5 6 7 8 9

5 6 7 8 9

5 6 7 8 9

5 6 7 8 9

5 6 7 8 9

5 6 7 8 9

5 6 7 8 9

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Dimension E

I-BACK ONLY

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

1.5

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

ORDERING INFORMATION: PHONE: (800) 333-4000 FAX: (800) 300-7502 WEBSITE: www.sunrisemedical.com


Page 9

2. Back Relief

SPO

Scapular

E2617

Scapular Cut-Out Back (Diagram C)

Complete Dimensions A, B, F & G


172GI03

Figure C - Scapular Relief Back

ART SPO CUSTOM CURVED BACKREST

Posterior Positioning Backrest (E2617)


$1,035.00

Back Relief Dimensions

Dim- ension

A

BACK

HEIGHT

14-17

Dimension B

BACK WIDTH

(must be same as Base Width)

Not Available

17.5

16 17 18 19 20

18 16 17 18 19 20

18.5

16 17 18 19 20

19 16 17 18 19 20

19.5

16 17 18 19 20

20 16 17 18 19 20

20.5

16 17 18 19 20

21 16 17 18 19 20

21.5

16 17 18 19 20

22 16 17 18 19 20

22.5

16 17 18 19 20

23 16 17 18 19 20

23.5

16 17 18 19 20

24 16 17 18 19 20

24.5

16 17 18 19 20

25 16 17 18 19 20

25.5

16 17 18 19 20

26 16 17 18 19 20

26.5

16 17 18 19 20

27 16 17 18 19 20

27.5

16 17 18 19 20

28 16 17 18 19 20

Dimension F Dimension G

Not Available Not Available

4

4

4 5

4 5

3 4 5 6

3 4 5 6

3 4 5 6

3 4 5 6

5 6 8

5 6 8

3 4 5 6

3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

6 7 8 9 3 4 5 6

Diagram C - Scapular Relief Back Diagram D - Foam Components

1" Standard

1.5"

2"

Custom Foam Thickness

Available on all Backs

2.5"

3"

ORDERING INFORMATION: PHONE: (800) 333-4000 FAX: (800) 300-7502 WEBSITE: www.sunrisemedical.com


Page 10

Quickie QM-715 HD Order Form (Rev. G)

Quickie QM-715™ HD Group 3

(K0848, K0856, K0861)

SUBMIT

1. QUICKIE QM-715™ HD GROUP 3 CATEGORY (Select One)

2. BASE CHAIR OPTIONS

STFH Matrix

3. BATTERIES and CHARGERS

4. ELECTRONICS

5. SEAT TYPE

6. SEAT SIZE

Seat Size Matrix.

ASAP II Seat Width

7. SEAT CUSHIONS

8. POWERED SEATING

9. BACKREST AND BACK OPTIONS for ASAP II (BC and SC)

10. BACKREST AND BACK OPTIONS for 3.7 POWER RECLINE (MPC)

JAY 3 BACK for 3.7 POWER RECLINE OPTIONS

SPINE-ALIGN MINI FIT KIT 2

11. HEADREST OPTIONS

12. POSTURAL SUPPORTS

13. ARMREST AND ARMPAD OPTIONS

13A. Armrest options for ASAP II seating.

Armpad Options for ASAPII

13B. Armrest options for Power Recline Seating

Armrest for Power Recline Seating.

Reclining Armpad Options

14. HANGERS AND FOOTRESTS FOR ASAP II

14. ACCESSORIES

ART SPO CUSTOM CURVED BACKREST

Posterior Positioning Backrest (E2617)

ART SPO CUSTOM CURVED BACKREST

Posterior Positioning Backrest (E2617)

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