Fillable DECEMBER 201 ACCOUNT INFORMATION (AMYLIOR)

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DECEMBER 201 ACCOUNT INFORMATION (AMYLIOR)

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▼ 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 (HD)
16 ¼" 19 ¼"
☐
VR2
☐
Alltrack RWD R (HD)
16 ½" 19 ½"
☐
Alltrack MWD HD
17" 19 ¼"
☐
R-Net 90
☐
R-Net 120
► Quickie
▼STFH w/ Tilt ▼STFH w/ Combo ▼ Electronics
☐
QM715
TBA TBA
☐
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 HD
17" 19"
☐
Dynamic Shark
☐
Q-Logic 3
☐
1450
17" 19"
☐
6 key VR2
☐
Q-Logic NE
☐
614 HD
TBA TBA
☐
Q-Logic 1 or 2
☐
Q-Logic NE +
► 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
☐
Storm 3G ☐ Short ☐ Long
17"
19 ½"
☐
Mk6 GTRAC
► Other Manufacturers
▼STFH w/ Tilt ▼STFH w/ Combo ▼ Electronics
☐
21st Century Big Bounder
TBA TBA
☐
21st Century Scientific
☐
IIM - Frontier V6
18 ½" 18 ½"
☐
IIM - PG R-Net
☐
IIM - X8 Extreme
19" 20"
☐
Other Power Wheelchair 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.
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)
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.F34) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT HD - USA (Rev.1)
Page 1 of 7
SAVE
RESET
ALL
PRINT
SEND
▼ INSTALLATION
☐
NOTE-IN-HOUSE Factory Installation STD
▲
▼ POWER OPTIONS & SEATING
☐
SAABAHD Amyseat HD Rehab Seat - Seat Frame only $1,995
☐
SAPTNHD HD CG Power Tilt (E1002) $4,650
▲
☐
SAPRNHD HD Power Recline with Integrated Shear Reduction (ISR) (E1004) $5,920
▲
☐
SAPTPRNHD HD CG Power Tilt and Power Recline with Integrated Shear Reduction (ISR) (E1007) $10,630
▲
☐
SAPESHD 11" HD Power Elevating Seat Module for transfer assist (E2300) $5,175
▲
☐
ADDPESHD (E2300) $3,995
▲
▼ 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
▼ 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
Dual actuator activation through the Joystick or Specialty Controls
Multiple (3 to 6 Actuators) Power Seat Function Controller to Interface through the Electronics
Tilt only activation through PG Drives R-Net EL Joysticks
Requires the P&G R-Net EL Joystick from Amysystems or Quickie
This option includes the Amyseat Rehab Seat (SAABAHD), Maximum user weight is 400lb with this option.
Maximum user weight is 400lb with this option.
This option includes the Amyseat Rehab Seat (SAABAHD).
It is recommended to use the NXT Back Support option with the power recline (NOACB or NOPCB)
This option includes the Amyseat Rehab Seat (SAABAHD).
It is recommended to use the NXT Back Support option with the power recline (NOACB or NOPCB)
The Wheelchair must be drop-shipped from the manufacturer or Delivered to Amysystems from the dealer
This option includes the Amyseat Rehab Seat (SAABAHD)
Module - Add an 11" HD Power Elevating Seat to either SAPTNHD, SAPRNHD or SAPTPRNHD
Single (1) Power Seat Function Controller to Interface through the wheelchair Electronics
Dual (2) Power Seat Function Controller to Interface through the wheelchair Electronics
Single actuator activation through the Joystick or Specialty Controls
Requires the Single (1 Actuator) Power Seat Function Controller (SAC) or the Dual (2 Actuators) Power Seat Function
Controller (DAC)
Requires the Single (1 Actuator) Power Seat Function Controller (SAC) or the Dual (2 Actuators) Power Seat Function
Controller (DAC)
Multiple Actuator activation through the Joystick or Specialty Controls
(MKT.F34) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT HD - USA (Rev.1)
Page 2 of 7
▼ 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
▼ PRE-SET BACK ANGLE (For Non-Reclining Backs)
☐
SOBAA
Please Select one: ☐ 82° ☐ 90° ☐ 98° ☐ 106°
N/C
▼ LARGE ADJUSTABLE SEAT WIDTH RANGE BETWEEN 19" AND 28"
☐ SOWN19-24-22 Width adjustment from 19" to 24" and Depth range of 18" to 22"
The minimum seat depth with this seat option is 18" Deep
N/C
☐ SOWN24-28-24 Width adjustment from 24" to 28" and Depth range of 18" to 24"
The minimum seat depth with this seat option is 18" Deep
N/C
☐ 19" (SOWN19L) ☐ 23" (SOWN23) ☐ 26" (SOWN26HDL)
☐ 20" (SOWN20L) ☐ 24" (SOWN
24) ☐ 2
7" (SOWN27HDL)
☐ 21" (SOWN21) ☐ 24" (SOWN24HDL) ☐ 28" (SOWN28HDL)
☐ 22" (SOWN
22) ☐ 25" (SOWN25HDL)
▼ CUSTOM WIDTH ABOVE 28"
☐
SOWCUS
Custom Seat Width
Specify: ________________
465.00$
▼ ADJUSTABLE SEAT DEPTH RANGE BETWEEN 18" AND 24"
☐
18" (SODN18)
☐
21" (SODN21)
☐
24" (SODN24)
☐
19" (SODN19)
☐
22" (SODN22)
☐
20" (SODN20)
☐
23" (SODN23)
▼ CUSTOM DEPTH ABOVE 24"
☐
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 recline.
☐ 18" (SOBCH18) ☐ 24" (SOBCH24)
☐
20" (SOBCH20)
☐ 26" (SOBCH26)
▼ CUSTOM BACK CANE HEIGHT ABOVE 27"
☐
SOBHCUS
Custom Back Cane Height
Specify: ________________
250.00$
▼ BACK SUPPORT
☐
STDSB Standard contour back support 19" to 28" 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" (SOBH
18)
☐ 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.
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 PC DEEP CONTOUR BACK (19" to 21" Wide)
NXT OPTIMA FH PC DEEP CONTOUR BACK (22" to 28" Wide)
The minimum space between the back and seat pan is 3" with a fixed back and 6" with a reclining back
NXT OPTIMA FH AC CONTOUR BACK (19" to 21" Wide)
NXT OPTIMA FH AC CONTOUR BACK (22" to 28" 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
(MKT.F34) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT HD - USA (Rev.1)
Page 3 of 7
▼ SEAT CUSHIONS
► CG Air - THERAPEUTIC AIR CUSHION
☐ Single Valve 19" to 21" Wide (E2622) CELL HEIGHT ☐ 2"
☐ Single Valve 22" to 28" 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 (19" 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" with 1" increments) STD
☐
SOAFBFRH Flip-Back Cantilever - Full Length Right Side (Height Adjustable from 7" to 15" with 1" increments) STD
☐
SOAFBDLH Flip-Back Cantilever - Desk Length Left Side (Height Adjustable from 7" to 15" with 1" increments) N/C
☐
SOAFBDRH Flip-Back Cantilever - Desk Length Right Side (Height Adjustable from 7" to 15" with 1" increments) N/C
▼ DUAL POST - HEIGHT ADJUSTABLE ARMRESTS - INCLUDES TRANSFER GRIPS (For Non-Reclining Backs - Choose 2)
☐
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" with ½" increments) N/C
☐
SOANIFRH Reclining armrest - Full Length Right Side (Height Adjustable from 10 ½" to 14" with ½" increments) N/C
☐
SOANIDLH Reclining armrest - Desk Length Left Side (Height Adjustable from 10 ½" to 14" with ½" increments) N/C
☐
SOANIDRH Reclining armrest - Desk Length Right Side (Height Adjustable from 10 ½" to 14" with 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
▼ 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.
(MKT.F34) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT HD - USA (Rev.1)
Page 4 of 7
▼ FOOTRESTS
☐
SOAAF**-STD
Adult Heavy Duty Swing-Away footrests
STD
Set at: ☐ 60° ☐ 70°
Select Footrest Range:
☐ SOFLHD12 (12 ½" - 15 ½")
☐
SOFLHD14 (14 ½" - 19 ½")
☐
ADDPLHD Adult Power Elevating & Articulating Legrests (E1010)
$3,895
▲
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 90° Heavy-Duty Fixed Center Mount Interface Bracket (Offers Manual adjustability from 94° to 70°) N/C
▲
Select Foot Platform Range: ☐ SOFBA12 (12 ½" - 16 ½")
☐ SOFBA16 (16 ½" - 19 ½")
☐ ADDPFHD 90° Heavy-Duty Power Center Mount Elevating & Articulating Foot Platform (E1012 / K0108) $3,895
▲
Select Foot Platform Range:
☐ ADDPFVH 90° Very Heavy-Duty Power Center Mount Elevating & Articulating Foot Platform (E1012 / K0108) $3,995
▲
Select Foot Platform Range:
▼ 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
▼ FOOT PLATEFORM LENGTH ADJUSTMENT AT FACTORY
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.
☐ SOFBPW12 (10 ½"- 16")
☐ SOFBPW16 (16"- 20")
☐
SOFBPW12 (10 ½"- 16")
☐ SOFBPW16 (16"- 20")
▼ FOOTREST LENGTH ADJUSTMENT AT FACTORY
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
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 or the Quickie S636 / S646. The Maximum user weight with this option is 450lb.
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 or the Quickie S636 / S646. The Maximum user weight with this option is 550lb.
This option includes calf pads. Individual legs count as two power functions. Combined legs count as one power function.
(MKT.F34) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT HD - USA (Rev.1)
Page 5 of 7
▼ 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
If only choosing one (1) armrest pouch, please show what side it should be installed
Armrest Side Pouch (Comes with durable straps that can be hooked around the armrest tubes)
Order ☐ Left Side ☐ Right Side
The Lateral Trunk Supports are not compatible with the NXT Optima FH PC 6" Deep Contour Fixed Thoracic Back Support (NOPCB)
(MKT.F34) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT HD - 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 Flip-up 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
Endomorphic Back Canes
(
Pair
)
□ 1" per side towards the inside = 2" in □ 2" per 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.F34) Specifications are subject to change without notice. Copyright @ 2018, Amylior Inc. (December 2018)
AMYSEAT HD - USA (Rev.1)
Page 7 of 7
www.amysystems.com / info@amysystems.com / Phone: 1 450 424-0288 / Fax: 1 450 424-7211
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DECEMBER 201 ACCOUNT INFORMATION (AMYLIOR)

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Completed 11 May 2021

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