Prescription

PRESCRIPTION/

Infinite Rehab

ORDER FORM Solutions

-SPORTS- 383 Obi Obi Road

Mapleton Q 4560

Ph: (07) 5445 7251

Mob: 0402 430 880

irsrehab@westnet.com.au

www.infiniterehb.com.au



SPECIALISING IN CUSTOM BUILT WHEELCHAIRS



Name:________________________________________________ Deliver To:_______________________________________



Street:_______________________________________________ Suburb:____________________________________________



State:_____________________ Postcode:_________________ Contact Number:______________________________________



E-mail: ______________________________________________ Mobile Number: ___________________________________





Measured Date:____________ Production Date:____________ Completed Date:____________ Delivery Date:______________



Invoice Date:_____________________ Invoice No:______________________ Serial No:___________________________



TOTAL PRICE/QUOTE:_________________









Please Tick Appropriate Box

CHAIR TYPE & PRICE



 Intimidator (Basketball) ------------------------------------- $2995.00

 Achiever (Tennis)-------------------------------------------- $2995.00

 Custom ___________________________ PRICE:__________



FRAME DIMENSIONS

Seat and Frame Width (mm)

 300  350  380  400  430  460  480

 500 Custom (please specify width)______________



Seat Upholstery Length (mm)

 300  350  380  400  430  460

 480  Custom (please specify length)_______________



Tapered Seat

 No  Yes (please specify amount.)_____________



SEAT HEIGHT

Front to Floor (mm) (Refer to A in diagram)

 530  500  480  450  420  Custom(please specify height)_____________

Rear to Floor (mm) (Refer to B in diagram)

 530  500  480  450  420  400  Custom(please specify height)______________

BACK HEIGHT (mm) (Refer to C in diagram)

 200  250  300  350  400  450  500  Custom (please specify height)_____________

Back Options

 Adjustable Height (Please specify adjustment range)_________to_______ Angle (please specify in degrees) ____________









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LOWER LEG LENGTH (mm)

 300  325  350  375  400  425  450  475  500  Custom (please specify length)__________



FOOT PLATE OPTION

 Fixed  Adjustable (Please specify adjustment range)________to________  Custom (Please specify) ______________



FOOT PLATE WIDTH (mm)

 180  200  220  240  260  Custom (please specify width)________________



FOOT PLATE LENGTH. (mm)

 240  260  280  300 .Custom (please specify length)________________



TOTAL LENGTH OF FRAME (backrest to front of footplate)

 550  575  600  625  650  675  700  Custom (Please specify length)_________



POINT OF BALANCE MEASUREMENT (measure from back of back canes to centre of rear wheel axle)

 80  90  100  110  120  130  140  150  160 .Custom (please specify)________________



WHEEL SIZE

 540mm (24")  559mm (25") (Additional $95)  590mm (26")  620 (700cc/27”) (Additional $95)



TYRE

 24” Long wear  26” Long wear  Primo High Pressure(559/25 & 590/26 only)(Additional $55)

 700cc/27”(Additional $55)



WHEEL CAMBER (degrees)

 15 (Std)  Custom (please specify degrees)_________________



CASTER OPTIONS (mm)

 72 Roller Blades  80 Roller Blades



FRAME COLORS

 Pearl White  Metallic Silver  Lemon Yellow  Hawthorn Green  Flame Red  Candy Red or Blue(Additional $55)

 Space Blue  Black Onyx  Gloss Black  Other ________________ Custom Color _______________ (Additional $55)



COMPONENTS COLOR (Consists of Forks, sideguards and footplate)(please specify from the above list) _________________



 Pearl Clear Finish (Additional $55)  Additional color (Additional $55)_________________________________



UPHOLSTERY COLOR

 Black



CUSHION OPTIONS (mm)

 50  75  100  Soft Density  Medium Density  Firm Density  None



OPTIONAL EXTRAS

 Calf strap $45.00  Spoke protectors $85.00

 Seat belt $55.00  Single pivoting anti tip system $145.00

 Foot strap Std  Double pivoting anti tip system $195.00

 Side guards (Aluminium) $95.00  Checkered Rubber Footplate cover $35.00







Specifications:

Approximate weight ------------------ 8kg (Depending upon size of wheelchair and added options)

Frame construction ------------------ Chome-moly or Aluminium

Upholstery material ------------------ 1000 Denier Cordura and Suede

Welding type ------------------------- Tig

Price: _____________________

Options: ____________________

NOTES:

____________________

____________________

____________________

_____________________

____________________

____________________

____________________

Freight: ____________________

GST: ____________________

TOTAL: ____________________



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