Fillable DECEMBER 201 ACCOUNT INFORMATION (AMYLIOR)

Fill Online, Printable, Fillable, Blank DECEMBER 201 ACCOUNT INFORMATION (AMYLIOR) Form

Use Fill to complete blank online AMYLIOR pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DECEMBER 201 ACCOUNT INFORMATION (AMYLIOR)

On average this form takes 50 minutes to complete

The DECEMBER 201 ACCOUNT INFORMATION (AMYLIOR) form is 7 pages long and contains:

  • 0 signatures
  • 301 check-boxes
  • 58 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your AMYLIOR forms online.

BROWSE AMYLIOR FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
▼ ACCOUNT INFORMATION
P.O. # or Quote:
Dealer Contact Name:
Email Address:
Phone Number: Fax Number:
Bill to (Name):
Bill to (Location):
Ship to (Name):
Address:
City:
State: Zip Code:
User Name or Number:
User Weight:
User Height:
Seat Cushion Thickness:
Knee to Heel Length: Left: Right:
The order cannot be processed without the following:
▼ POWER BASE SELECTION & ELECTONICS
▲
► Amysystems
▼STFH w/ Tilt ▼STFH w/ Combo ▼ Electronics
☐ Alltrack MWD ☐ M ☐ P
16 ¼" 18 ¼"
☐ VR2
☐ Alltrack RWD ☐ R ☐ P
16 ½"
18 ½"
☐ R-Net 90 ☐ R-Net 120
► Quickie
▼STFH w/ Tilt ▼STFH w/ Combo ▼ Electronics
☐ Pulse 6
16 ¾" 18 ¾"
☐ VR2
☐
TBA TBA
☐ 6 key VR2
☐ P220 / P222 ☐ Std. ☐ Wide
18 ½" N/A
☐ R-Net 90 ☐ R-Net 120
☐ S636 / S646 ☐ Std ☐ Wide
17 ¼" 19 ½"
▲ Additional charges may apply if base is equiped with anti-tip cables
► Pride Quantum
▲
▲
▲
▲
▼STFH w/ Tilt ▼STFH w/ Combo ▼ Electronics
☐ Q6 Edge, Edge 2.0
17" 19"
☐ VR2 ☐ Q-Logic 3
☐ J6
17" 19"
☐ 6 key VR2 ☐ Q-Logic NE
☐ 4Front
TBA TBA
☐ Dynamic Shark ☐ Q-Logic NE +
☐ Rival
TBA TBA
☐ Q-Logic 1 or 2
► Invacare
▼STFH w/ Tilt ▼STFH w/ Combo ▼ Electronics ▼ Joysticks
☐ FDX
TBA TBA
☐ Mk690 ☐ SPJ
☐ TDX SP ☐ GP 22 ☐ GP 24
16 ½" 19"
☐ Mk690ACC ☐ MPJ / DISPLAY
☐ TDX SR
17"
19 ½"
☐ Mk6TT
☐ TDX SC (Spree)
15 ½"
17 ½"
☐ Mk6 GTRAC
☐ Storm 3G ☐ Short ☐ Long
17"
19 ½"
► Other Manufacturers
▼STFH w/ Tilt ▼STFH w/ Combo ▼ Electronics
☐ Golden Compass
16 ½" 19"
☐ Golden - Dynamic Shark
☐ Rovi x3
TBA TBA
☐ Rovi - R-Net
☐ IIM - Frontier V6
18 ½" 18 ½"
☐ IIM - PG R-Net
☐ IIM - X8 Extreme
19" 20"
☐ Trackmaster MK1
19 ½" 20 ½"
☐ Trackmaster - R-net
☐ Other Power Wheelchair Specify: ________________
Seat to floor height (STFH) is measured at the front of the seat pan with a 0° Pre-Tilt. Lowest STFH (within ¼") is shown below.
When a chair is equipped with a seat elevate with any Q-Logic electronics, reduced speed requires power seating options through drive controls (SWTJSS, SWTJSD or SWTJSM)
QM Series -Specify:__________
DECEMBER 201
8
IN RED SHOWS THE ADDITION OF NEW OPTIONS, UPGRADES, PRICING MODIFICATIONS OR ADDED NOTES
- A user name or number, the client’s measurements and weight
- Amysystems is not responsible for configuration or size discrepancies resulting from customer errors on the order form.
- Order confirmations will be provided by Amysystems summarizing the items selected. Please review this carefully.
- Once the order is shipped, any changes are subject to the returns policy and may be prohibited.
Q-Logic NE is not compatible with through joystick activation of the power seating options and does not offer reduced speed with seat elevator. Only Drive-Lock-out is available.
Q-Logic NE+ is only available for a maximum of two actuators for through the Joystick activation. It is only compatible with Tilt / Power Elevating Center Mount or Elevate / Power
Elevating Center Mount. Multiple power use is possible with the MAC box but does not offer reduce speed with the seat elevate. Only Drive-Lock-out is available with Seat Elevate, and
only external switch activations can be used (Not available with activation through the Joystick).
Dynamic Shark is only available for a maximum of two actuators with external switches. For through the joystick activation, only one actuator can be used and it requires one of the
following joysticks be used: Shark PSS or Shark ACC joysticks
(MKT.F33) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT - USA (Rev.1)
Page 1 of 7
SAVE
RESET
ALL
PRINT
SEND
▼ INSTALLATION
☐ NOTE-IN-HOUSE STD
▲
▼ POWER OPTIONS & SEATING
☐ SAABA $1,495
☐ SAPTN CG Power Tilt (E1002) $4,075
▲ This option includes the Amyseat Rehab Seat (SAABA)
☐ SAPRN Power Recline with Integrated Shear Reduction (ISR) (E1004) $5,580
▲
☐ SAPTPRN CG Power Tilt and Power Recline with Integrated Shear Reduction (ISR) (E1007) $8,795
▲
☐ SAPES 11" Power Elevating Seat Module for transfer assist (E2300) $4,175
▲ This option includes the Amyseat Rehab Seat (SAABA)
☐ ADDPES (E2300) $2,995
☐ ADDMR Module - Manual Recline with Integrated Shear Reduction (ISR) (E1226) $1,280
▲
▼ ELECTRONICS - SINGLE OR DUAL (1 OR 2 ACTUATORS) POWER SEAT FUNCTION CONTROLLERS
☐ SAC (E2310) $2,895
☐ DAC (E2310) $3,695
With the SAC or DAC, please select one activation and position from the list below
☐ SWTOGGLE Single Toggle Switch (Single Mode: DAC - Dual Mode: SAC) ☐ User ☐ Attendant STD
▲
☐ SWPUSH1 Single Push Button Switch (Single Mode: SAC) ☐ User ☐ Attendant STD
▲ Requires the Single (1 Actuator) Power Seat Function Controller (SAC)
☐ SWPUSH2 Dual Push Button Switch (Single Mode: DAC - Dual Mode: SAC) ☐ User ☐ Attendant STD
▲
☐ SWTJSS N/C
▲ Requires the Single (1 Actuator) Power Seat Function Controller (SAC)
☐ SWTJSD N/C
▲ Requires the Dual (2 Actuators) Power Seat Function Controller (DAC)
☐ SWTVR2 Tilt only activation through 6-key PG Drives VR2 Joysticks N/C
▲ Requires the P&G 6-Key VR2 Joystick from Amysystems, Quickie or Pride.
☐ EPSEL N/C
▲
☐ SWTMK6-ACCT Tilt only activation through Invacare: ☐ SPJ-PSS ☐ SPJ-ACC ☐ MPJ N/C
▲ Requires the SPJ-ACC, SPJ-PSS or MPJ Joystick with the MK690-ACC controller from Invacare.
▼ ELECTRONICS - MULTIPLE (3 to 6 ACTUATORS) POWER SEAT FUNCTION CONTROLLER
☐ MAC (E2311) $3,695
With the MAC, please select one activation and position from the list below
☐ SWMULTI 4-Way Toggle Switch (Up to 4 Activations) ☐ User ☐ Attendant N/C
▲ Requires the Multiple (3 to 6 Actuators) Power Seat Function Controller (MAC)
☐ SWMULTIT Triple Toggle Switch (Up to 5 Activations) ☐ User ☐ Attendant N/C
▲ Requires the Multiple (3 to 6 Actuators) Power Seat Function Controller (MAC)
☐ SWPUSH4 4-Way Push Button Switch ☐ User ☐ Attendant N/C
▲ Requires the Multiple (3 to 6 Actuators) Power Seat Function Controller (MAC)
☐ SWPUSH5 5-Way Push Button Switch ☐ User ☐ Attendant N/C
▲ Requires the Multiple (3 to 6 Actuators) Power Seat Function Controller (MAC)
☐ SWTJSM STD
▲ Requires the Multiple (3 to 6 Actuators) Power Seat Function Controller (MAC)
▼ SWITCH ACTIVATION HAND MOUNT
☐ TSML Install Switch on LH side N/C
☐ TSMR Install Switch on RH side N/C
Amyseat Rehab Seat - Seat Frame only
Factory Installation
Single actuator activation through the Joystick or Specialty Controls
Dual actuator activation through the Joystick or Specialty Controls
Single (1) Power Seat Function Controller to Interface through the wheelchair Electronics
Dual (2) Power Seat Function Controller to Interface through the wheelchair Electronics
This option includes the Amyseat Rehab Seat (SAABA).
It is recommended to use the NXT Back Support option with the power or manual reclines (NOACB or NOPCB)
It is recommended to use the NXT Back Support option with the power or manual reclines (NOACB or NOPCB)
The maximum user weight capacity with this option is 250 lb
This option includes the Amyseat Rehab Seat (SAABA).
It is recommended to use the NXT Back Support option with the power or manual reclines (NOACB or NOPCB)
Requires the Single (1 Actuator) Power Seat Function Controller (SAC) or the Dual (2 Actuators) Power Seat Function
Controller (DAC)
The Wheelchair must be drop-shipped from the manufacturer or Delivered to Amysystems from the dealer
Module - Add an 11" Power Elevating Seat to either SAPTN, SAPRN or SAPTPRN
Requires the Single (1 Actuator) Power Seat Function Controller (SAC) or the Dual (2 Actuators) Power Seat Function
Controller (DAC)
Multiple (3 to 6 Actuators) Power Seat Function Controller to Interface through the Electronics
Multiple Actuator activation through the Joystick or Specialty Controls
Tilt only activation through PG Drives R-Net EL Joysticks
Requires the P&G R-Net EL Joystick from Amysystems or Quickie
(MKT.F33) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT - USA (Rev.1)
Page 2 of 7
▼ JOYSTICK MOUNT
☐
SOSWJSM
Swing Away Joystick Mount - Height adjustable, Angle adjustable and Multi-Axis
(E1028)
$375
☐ Set-up with standard installation to swing-away sideways
☐ Set-up at 35° to swing-away sideways and downwards
▼ JOYSTICK MOUNT SUPPORT
☐
JSMFH
Joystick mount support Bracket STD
▼ JOYSTICK HAND MOUNT
☐ HML Install Joystick on Left hand side
☐ HMR Install Joystick on Right hand side
☐ SOBAA Please select one: ☐ 86° ☐ 94° ☐ 102° ☐ 110° ☐ 118° N/C
☐ 90° ☐ 98° ☐ 106° ☐ 114° ☐ 122°
▼ PEDIATRIC ADJUSTABLE SEAT WIDTH RANGE BETWEEN 11" AND 16"
☐ SOWN11-16 Width adjustment from 11" to 16" and Depth range of 11" to 16" N/C
▲ Seat to Floor Height increases by 1¼"
N/C
☐ 11" (SOWN11) ☐ 13" (SOWN13) ☐ 15" (SOWN15)
☐ 12" (SOWN12) ☐ 14" (SOWN14) ☐ 16" (SOWN16)
▼ PEDIATRIC ADJUSTABLE SEAT DEPTH RANGE BETWEEN 11" AND 16"
☐ 11" (SODN11) ☐ 13" (SODN13) ☐ 15" (SODN15)
☐ 12" (SODN12) ☐ 14" (SODN14) ☐ 16" (SODN16)
▼ STANDARD ADJUSTABLE SEAT WIDTH RANGE BETWEEN 15" AND 20"
☐ SOWN15-20-19 Width adjustment from 15" to 20" with a maximum Depth of 19" N/C
☐ SOWN15-20-22 N/C
☐ 15" (SOWN15) ☐ 17" (SOWN17) ☐ 19" (SOWN19S
)
☐ 16" (SOWN16) ☐ 18" (SOWN18) ☐ 20" (SOWN20S)
▼ LARGE ADJUSTABLE SEAT WIDTH RANGE BETWEEN 19" AND 24"
☐ SOWN19-24-22 N/C
☐ 19" (SOWN19L) ☐ 21" (SOWN21) ☐ 23" (SOWN23)
☐ 20" (SOWN20L) ☐ 22" (SOWN22) ☐ 24" (SOWN24)
▼ CUSTOM WIDTH ABOVE 25"
☐ SOWCUS Custom Seat Width Specify: ________________ 465.00$
▼ ADJUSTABLE SEAT DEPTH RANGE BETWEEN 15" AND 22"
☐ 15" (SODN15) ☐ 18" (SODN18) ☐ 21" (SODN21)
☐ 16" (SODN16) ☐ 19" (SODN19) ☐ 22" (SODN22)
☐ 17" (SODN17) ☐ 20" (SODN20)
▼ CUSTOM DEPTH ABOVE 22"
☐ SODCUS Custom Seat Depth Specify: ________________ 250.00$
▼ BACK CANE HEIGHT (The back cane height measurement is taken from the seat pan to the top of the push handles)
☐ 16" (SOBCH16) ☐ 22" (SOBCH22)
22" is the minimum back cane height required with a power or manual recline.
☐ 18" (SOBCH18) ☐ 24" (SOBCH24)
☐ 20" (SOBCH20) ☐ 26" (SOBCH26)
▼ CUSTOM BACK CANE HEIGHT ABOVE 27"
☐ SOBHCUS Custom Back Cane Height Specify: ________________ 250.00$
Width adjustment from 15" to 20" with a maximum Depth of 22"
The minimum seat depth with this seat option is 18" Deep
Width adjustment from 19" to 24" and Depth range of 18" to 22"
The minimum seat depth with this seat option is 18" Deep
With a 22" long Seat Pan SOWN15-20-22 and SOWN19-24-22, the minimum possible seat depth is 18".
▼ PRE-SET BACK ANGLE (For Non-Reclining Backs)
(MKT.F33) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT - USA (Rev.1)
Page 3 of 7
▼ BACK SUPPORT
☐ STDSB Standard contour back support 15" to 24" Wide with a maximum shell height of 22" (Not Coded) N/C
▲
☐ NOACB- (E2620) $660
☐ NOACB- (E2621) $705
▲
☐ NOPCB- NEW! (E2620) $660
☐ NOPCB- NEW! (E2621) $705
▲
☐ STDSBO Omission of the Contour Back Support Specify Model of Back Support: ___________________
__
N/C
▲ It is recommended to use the Back Support option with the power or manual recline.
▼ BACK SUPPORT TOTAL HEIGHT (MEASURED FROM THE SEAT PAN TO THE TOP OF THE BACK)
☐ 16" (SOBH16) ☐ 24" (SOBH24)
☐ 18" (SOBH18) ☐ 26" (SOBH26)
☐ 20" (SOBH20) ☐ 28" (SOBH28)
This height is not available with the NXT Optima option (NOACB or NOPCB)
☐ 22" (SOBH22)
22" is the minimum back height required with a power or manual recline.
▼ SEAT CUSHIONS
► CG Air - THERAPEUTIC AIR CUSHION
☐ Single Valve 15" to 21" Wide (E2622) CELL HEIGHT ☐ 2"
☐ Single Valve 22" to 24" Wide (E2623) ☐ 3"
☐ Custom Cushion (Please use the CG Air Order Form) ☐ 4"
☐ CGA1VSCxxxx-x CG Air Single Valve (with Standard 2-way Stretch Cover) $510
☐ CGA1V3Dxxxx-x CG Air Single Valve (with 3D Mesh Cover) $564
☐ CGA1VICxxxx-x CG Air Single Valve (with Incontinence Cover) $535
▲ The actual cushion sizes only come in even numbers for width and depth measurements.
► NXT BIO-FIT CUSHION
☐ NXTBIOFIT NXT BIO FIT Cushion (15" to 21" Wide) (E2607) $418
☐ NXTBIOFIT NXT BIO FIT Cushion (22" to 24" Wide) (E2608) $445
▲ The actual cushion sizes only come in even numbers for width and depth measurements.
▼ CANTILEVER - HEIGHT ADJUSTABLE ARMRESTS - OPENS WITH A 5° ANGLE (For Non-Reclining Backs - Choose 2)
☐ SOAFBFLH Flip-Back Cantilever - Full Length Left Side (Height Adjustable from 7" to 15" in 1" increments) STD
☐ SOAFBFRH Flip-Back Cantilever - Full Length Right Side (Height Adjustable from 7" to 15" in 1" increments) STD
☐ SOAFBDLH Flip-Back Cantilever - Desk Length Left Side (Height Adjustable from 7" to 15" in 1" increments) N/C
☐ SOAFBDRH Flip-Back Cantilever - Desk Length Right Side (Height Adjustable from 7" to 15" in 1" increments) N/C
▼ DUAL POST - HEIGHT ADJUSTABLE ARMRESTS - INCLUDES TRANSFER GRIPS (For Non-Reclining Backs - Choose 2)
☐ SOADPPLH Pediatric Dual Post Height Adjustable - Left Side (Height Adjustable from 7 ¼" - 10 ¼") (E0973) $120
☐ SOADPPRH Pediatric Dual Post Height Adjustable - Right Side (Height Adjustable from 7 ¼" - 10 ¼") (E0973) $120
☐ SOADPFLH Dual Post Height Adjustable - Full Length Left Side (Height Adjustable from 10 ¼" - 15 ¼") (E0973) $120
☐ SOADPFRH Dual Post Height Adjustable - Full Length Right Side (Height Adjustable from 10 ¼" - 15 ¼") (E0973) $120
☐ SOADPDLH Dual Post Height Adjustable - Desk Length Left Side (Height Adjustable from 10 ¼" - 15 ¼") (E0973) $120
☐ SOADPDRH Dual Post Height Adjustable - Desk Length Right Side (Height Adjustable from 10 ¼" - 15 ¼") (E0973) $120
▼ RECLINING FLIP-UP, HEIGHT ADJUSTABLE ARMRESTS (For Reclining Backs - Choose 2)
☐ SOANIFLH Reclining armrest - Full Length Left Side (Height Adjustable from 10 ½" to 14" in ½" increments) N/C
☐ SOANIFRH Reclining armrest - Full Length Right Side (Height Adjustable from 10 ½" to 14" in ½" increments) N/C
☐ SOANIDLH Reclining armrest - Desk Length Left Side (Height Adjustable from 10 ½" to 14" in ½" increments) N/C
☐ SOANIDRH Reclining armrest - Desk Length Right Side (Height Adjustable from 10 ½" to 14" in ½" increments) N/C
▼ ARMREST HEIGHT ADJUSTMENT AT FACTORY
Please set the Armrest Height at: __________ "
▲ The Armrest Height is taken from the seat pan to the top of the armpad. Not required for Dual Post
NXT OPTIMA FH PC DEEP CONTOUR BACK (22" to 24" Wide)
The actual back shell heights only come in 13", 16" or 19" high. The minimum space between the back and seat pan is 3" with a fixed
back and 6" with a reclining back
The minimum space between the back and seat pan is 3" with a fixed back and 6" with a reclining back
The actual back shell heights only come in 13", 16" or 19" high. The minimum space between the back and seat pan is
3" with a fixed back and 6" with a reclining back. This product is not compatible with Lateral Trunk Supports
NXT OPTIMA FH AC CONTOUR BACK (15" to 21" Wide)
NXT OPTIMA FH AC CONTOUR BACK (22" to 24" Wide)
NXT OPTIMA FH PC DEEP CONTOUR BACK (15" to 21" Wide)
(MKT.F33) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT - USA (Rev.1)
Page 4 of 7
▼ ARMPADS
► Foam Type Selection
☐ SOWAPD Desk Length Waterfall (10") Select Side: ☐ Left ☐ Right STD
▲ The Waterfall armpads may interfere with flipping back the armrests when combined with Lateral Trunk supports
☐ SOWAPF Full Length Waterfall (14") Select Side: ☐ Left ☐ Right STD
▲ The Waterfall armpads may interfere with flipping back the armrests when combined with Lateral Trunk supports
► Hybrid Gel and Foam Type Selection (The Gel always stays soft)
☐ SOGELD Desk Length Hybrid Gel and Foam Flat armpad (10") Select Side: ☐ Left ☐ Right $35
☐ SOGELF Full Length Hybrid Gel and Foam Flat armpad (14") Select Side: ☐ Left ☐ Right $35
☐ SOWGELD Desk Length Hybrid Gel and Foam Waterfall armpad (10") Select Side: ☐ Left ☐ Right $45
▲ The Waterfall armpads may interfere with flipping back the armrests when combined with Lateral Trunk supports
☐ SOWGELF Full Length Hybrid Gel and Foam Waterfall armpad (14") Select Side: ☐ Left ☐ Right $45
▲ The Waterfall armpads may interfere with flipping back the armrests when combined with Lateral Trunk supports
► Specialty Type Selection
☐ SOCAR
Arm Trough with Hand Support (18" x 4 ½") (E2209)
Select Side: ☐ Left ☐ Right $128
▲ Arm Trough Armpads may interfere with Armrests Flipping back.
▼ FOOTRESTS
☐ SOPAAF
Pediatric Swing-Away Footrests
STD
▲ Depending on seat configuration, 70°, 80° and 90° might not be available.
Set at: ☐ 60° ☐ 70° ☐ 80° ☐ 90°
Select Footrest Range: ☐ SOFLP5 (5 ½" - 7 ½")
☐ SOFLP8 (8 ½" - 10 ½")
☐ SOFLP10 (10 ½" - 15 ½")
☐ SOSAAF
Adult Swing-Away Footrests
STD
▲ This option is not available with the pediatric seat frame.
Set at: ☐ 60° ☐ 70°
Select Footrest Range: ☐ SOFLA10 (10 ½" - 15 ½")
☐ SOFLA14 (14 ½" - 19 ½")
☐
SOAAF
Adult Heavy Duty Swing-Away footrests
$475
▲ This option is not available with the pediatric seat frame.
Set at: ☐ 60° ☐ 70°
Select Footrest Range: ☐ SOFLHD12 (12 ½" - 15 ½")
☐ SOFLHD14 (14 ½" - 19 ½")
☐ ADDPL Adult Power Elevating & Articulating Legrests (E1010) $3,795
▲
Please Select Function: ☐ Individual
☐ Combined
Select Footrest Range: ☐ SOFLPW12 (12 ½" - 15 ½")
☐ SOFLPW14 (14 ½" - 19 ½")
▼ FOOTPLATES & ACCESSORIES
☐ SOSFAF Flip-up Footplates STD
☐ SOAFP Angle Adjustable & Flip-up Footplates - Each (K0040) $85
☐ SOAHL Heel Loops - Each (E0951) $21
☐ SOACPFR Calf Pads for Adult Heavy-Duty Swing-Away footrests (SOAAF) with adjustable hardware - Each (E0995) $38
Please set the Footrest Length at: __________ "
The Footrest Length is taken from the top of the seat pan to the top of the footplate.
▼ CENTER MOUNTS
☐ SOAAF90 N/C
▲
Select Foot Platform Range: ☐ SOFBA12 (12 ½" - 16 ½")
☐ SOFBA16 (16 ½" - 19 ½")
☐ ADDPF NEW! 90° Power Center Mount Elevating & Articulating Foot Platform (E1012 / K0108) $3,795
▲
Select Foot Platform Range:
90° Fixed Center Mount Interface Bracket (Offers Manual adjustability from 94° to 70°)
☐ SOFBPW12 (10 ½"- 16")
Please Select the one piece center mount foot platform (SOFUFP) or the split footplates (SOAFPFB). With the split
footplates option (SOAFPFB), this bracket offers independent height adjustability for each footplate. This option is not
compatible with RWD models such as the Invacare Storm, Quickie S636 / S646, Quickie P220 / P222, Pride Rival
This option includes calf pads. The power center mount counts as one power function. Please Select the one piece
center mount foot platform (SOFUFP) or the split footplates (SOAFPFB). This option is not compatible with RWD
models such as the Invacare Storm, Quickie S636 / S646, Quickie P220 / P222, Pride Rival
This option is not available with the pediatric seat frame. This option includes calf pads. Individual legs count as two
power functions. Combined legs count as one power function.
☐ SOFBPW16 (16"- 20")
▼ FOOTREST LENGTH ADJUSTMENT AT FACTORY
(MKT.F33) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT
- USA (Rev.1)
Page 5 of 7
▼ FOOT PLATFORMS & ACCESSORIES
☐ SOFUFP Flip-up one piece Foot Platform N/C
☐ SOAFPFB Angle Adjustable & Flip-up Split Footplates for center mount - Each (K0040) $85
☐ SOACPCM Calf Pads for 90° Fixed Center Mount (SOAAF90) with adjustable hardware - Each (E0995) $38
Please set the Foot Platform Length at: __________ "
The Foot Platform Length is taken from the top of the seat pan to the top of the foot platform or split foot plates.
▼ SEAT POSITIONING
☐ SOAUTO 55" Seat Positioning Strap STD
☐ SOAUTO80 80" Seat Positioning Strap $75
☐ SOBPHP2C Bodypoint padded Hip Belt (Two Point - Center Pull) (E0978) $150
☐ SOBPCS Bodypoint padded Chest Strap (E0960) $215
▼ HEADREST
Please select one of the headrest options with the mounting hardware and specify where the headrest will be installed
☐ SONUAHR Using headrest mounting hardware other than SOMAH located bellow. Specify: _________________
☐ SOFHRS Small Curved Headrest Pad 4" x 9" (E0955) $233
☐ SOFHRM Medium Curved Headrest Pad 5" x 10" (E0955) $233
☐ SOFHRL Large Curved Headrest Pad 6" x 11" (E0955) $233
☐ SOMAH Multi-axis Removable Mounting Hardware (E1028) $238
☐ SOHRBC Bracket to Mount on the Contour Back Support (Without Recline) N/C
☐ SOHRPR Bracket to Mount on the Seat Frame (For Reclining Backs)N/C
▼ LATERAL TRUNK SUPPORTS
Please select one of the lateral pads and the adjustable & removable hardware.
☐ SOSLS3 Adjustable Laterals with Small Curved Pads (Each) - 3" x 5" (E0956) $112
☐ SOSLM4 Adjustable Laterals with Medium Curved Pads (Each) - 4" x 6" (E0956) $112
☐ SOSLL5 Adjustable Laterals with Large Curved Pads (Each) - 5" x 7" (E0956) $112
☐ SOSLHM Adjustable Swing-Away Hardware Mounts - Each (E1028) $238
▲
▼ HIP & THIGH SUPPORTS
Please select one of the hip & thigh support pads and the adjustable & removable hardware.
☐ SOHTSS10 Adjustable Hip & Thigh Support Pads (Each) - Small 10" x 4" (E0956) $112
☐ SOHTSM12 Adjustable Hip & Thigh Support Pads (Each) - Medium 12" x 5" (E0956) $112
☐ SOHTSL14 Adjustable Hip & Thigh Support Pads (Each) - Large 14" x 6" (E0956) $112
☐ SOHTSARH Adjustable and Removable Hip & Thigh Support Hardware - Each (E1028) $238
▼ ACCESSORIES
☐ SOCH Cup Holder (Self-Leveling) $90
☐ SOCPH Ram Mounts X-Grip Cell Phone Holder $120
☐ SOTHS Ram Mounts X-Grip Small Tablet Holder $170
☐ SOTHL Ram Mounts X-Grip Large Tablet Holder with Swivel $270
▼ BACK PACK AND ARMREST SIDE POUCHES
☐ SOBP Back Pack (Comes with durable straps that can be hooked around the back canes) $79
☐ SOAP
$57
▲
▼ SWITCHES AND OPTIONS
☐ SSBS Buddy Button Switch (K0108) $150
☐ SSES Egg Switch-Black (K0108) $150
☐ SSML Ultra Light Switch (K0108) $155
Armrest Side Pouch (Comes with durable straps that can be hooked around the armrest tubes)
Order ☐ Left Side ☐ Right Side
If only choosing one (1) armrest pouch, please show what side it should be installed
The Lateral Trunk Supports are not compatible with the NXT Optima FH PC 6" Deep Contour Fixed Thoracic Back Support (NOPCB)
▼ FOOT PLATFORM LENGTH ADJUSTMENT AT FACTORY
(MKT.F33) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT - USA (Rev.1)
Page 6 of 7
▼ CUSTOM SECTION
Lead times will increase depending on the custom order pipeline at the time the purchase order is received. Please call for Quote and specifications for these options.
▼ O
2
Holder
☐ SUPOXY Custom Non-Articulating Oxygen Tank Holder (E2208) $270
▲ Not available with a power tilt and/or power recline
☐ SUPOXYA Custom Articulating Oxygen Tank Holder (K0108) $1,195
▲ Required with a power tilt and/or power recline
☐ D-Size Oxygen Tank (* 22" Tall x 4.3" Diameter) * The height includes the valve
☐ E-Size Oxygen Tank (* 31" Tall x 4.3" Diameter) * The height includes the valve
☐ MLH (Mount on Left)
☐ MRH (Mount on Right)
▼ VENT TRAY (Please complete in Full)
Amysystems does not supply the battery, charger or the wiring for the Vent. These items are normally provided by the Vent Manufacturer.
☐ SOVENT Custom Vent Tray
☐ Articulating Vent Box (E1030) $1,420
▲ Required with Power Tilt and/or Recline
☐ Fixed Vent Box (E1029) $400
Specify Vent Model: ________________________
☐ SOVTBE Custom Tray for Ventilator Battery (K0108) $495
☐ The Vent is being powered by 1 U1 Battery
☐ The Vent is being powered by 1 22NF Battery
☐ The Vent is being powered by 1 Group 24 Battery
☐ The Vent is being powered by 1 Group 34 Battery
▼ CUSTOM SECTION - Continued
Lead times will increase depending on the custom order pipeline at the time the purchase order is received. Please call for Quote and specifications for these options.
▼ OTHER CUSTOM OPTIONS (Request For Quote)
Please specify details and specifications for these options.
☐ CUSTOM Power Anterior Tilt RFQ
☐ CUSTOM
4-Point wheelchair tie downs
RFQ
▲
☐ CUSTOM
Power Lateral Tilt 15° ☐ Raise the Left Side only ☐ Raise the Right Side only ☐ Raise the Left & Right Side
RFQ
☐ CUSTOM Power Elevating Stretcher (Please call CSR for availability with configuration and user weight capacity) RFQ
☐ CUSTOM Power Flip-up Foot Platform (Please call CSR for availability with configuration and user weight capacity) RFQ
☐ CUSTOM Power Vertical Lifting Foot Platform (Please call CSR for availability with configuration and user weight capacity) RFQ
☐ CUSTOM Independent Depth Adjustability built into the Footrest Receiver that is attached to the Seat Pan RFQ
☐ CUSTOM
Endomor
p
hic Back Canes
(
Pair
)
□ 1"
p
er side towards the inside = 2" in □ 2"
p
er side towards the inside = 4" in
RFQ
☐ CUSTOM Transfer Handles (Pair) RFQ
☐ CUSTOM # 1 Other custom options. Specify in notes section bellow. RFQ
☐ CUSTOM # 2 Other custom options. Specify in notes section bellow. RFQ
▼ SEAT TO FLOOR HEIGHT SPECIFICATION (If not standard)
☐ SOMHSS Specific seat to floor height requirement other than standard. RFQ
Specify at: _______________" (± ¼" Range)
▼ NOTES / SPECIAL REQUESTS / CUSTOM SPECIFICATIONS
4-Point wheelchair transport brackets are not crash-tested in accordance with WC-19, Use these transport brackets
only to secure an unoccupied wheelchair during transport.
(MKT.F33) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT - USA (Rev.1)
Page 7 of 7
www.amysystems.com / info@amysystems.com / Phone: +1 450 424-0288 / Fax: +1 450 424-7211
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DECEMBER 201 ACCOUNT INFORMATION (AMYLIOR)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document