Fillable (E2622) $680 ACCOUNT INFORMATION CG Air Single Valve

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(E2622) $680 ACCOUNT INFORMATION CG Air Single Valve

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(E2622) $680
(E2622) $800
(E2622) $705
(E2624) $680
(E2624) $800
(E2624) $705
16" x 16" Qty: ______
16" x 18" Qty: ______
18" x 16" Qty: ______
(E2623) $880
(E2623) $1,060
(E2623) $925
(E2625) $880
(E2625) $1,060
(E2625) $925
22" x 22" Qty: ______
24" x 20" Qty: ______
(E2623) $1,185
(E2623) $1,415
(E2623) $1,245
(E2625) $1,185
(E2625) $1,415
(E2625) $1,245
28" x 20" Qty: ______
28" x 22" Qty: ______
28" x 24" Qty: ______
(E2619) $130
(E2619) $150
(E2619) $130
$31
$149
□
2"
(Only available in Single Valve)
□
3"
□
4"
REPLACEMENT COMPONENTS
CG Air Dual Valve (Includes Two (2) 3D Mesh Covers)
26" x 20" Qty: ______
□
CGA2V2ICxxxx-x CG Air Dual Valve (Includes Two (2) Incontinence Covers)
SELECT CELL HEIGHT
26" x 22" Qty: ______
CGA2V2SCxxxx-x CG Air Dual Valve (Includes Two (2) Standard 2-way Stretch Covers)
□
CGA2V23Dxxxx-x
CGA1V2ICxxxx-x CG Air Single Valve (Includes Two (2) Incontinence Covers)
DUAL (2) VALVE
□
14" to 20" WIDE
20" x 18" Qty: ______
20" x 20" Qty: ______
Other, specify __________ Qty: ______
18" x 20" Qty: ______
18" x 18" Qty: ______
□
□
□
CG Air THERAPEUTIC SEAT CUSHION
Zip Code:
City:
State:
User Name or Number:
VA (Billing):P.O. # or Quote:
Shipping Name:
ORDERING INFORMATION: PHONE: (888) 453-0311, FAX: (877) 501-8458, EMAIL: info@amylior.com
ACCOUNT INFORMATION
(VA) - October 2020
Email Address:
Fax Number:
Phone Number:
Ship Address:
Contact Name:
CG Air Single Valve (Includes Two (2) 3D Mesh Covers)
□
CGA1V2SCxxxx-x
CGA1V23Dxxxx-x
CGA1V2ICxxxx-x
CG Air Single Valve (Includes Two (2) Standard 2-way Stretch Covers)
20" x 16" Qty: ______
CGA2V2ICxxxx-x CG Air Dual Valve (Includes Two (2) Incontinence Covers)
SINGLE (1) VALVE
□
CGA1V2SCxxxx-x
14" x 14" Qty: ______
26" + WIDE
□
CGA1V23Dxxxx-x
14" x 16" Qty: ______
16" x 14" Qty: ______
CGA2V2ICxxxx-x
SINGLE (1) VALVE
DUAL (2) VALVE
□
CGA2V2SCxxxx-x CG Air Dual Valve (Includes Two (2) Standard 2-way Stretch Covers)
□
CGA2V23Dxxxx-x CG Air Dual Valve (Includes Two (2) 3D Mesh Covers)
CG Air Single Valve (Includes Two (2) 3D Mesh Covers)
CG Air Single Valve (Includes Two (2) Incontinence Covers)
□
22" to 24" WIDE
SINGLE (1) VALVE
□
CGA1V2SCxxxx-x CG Air Single Valve (Includes Two (2) Standard 2-way Stretch Covers)
SELECT CELL HEIGHT
□
2"
(Only available in Single Valve)
□
3"
□
4"
CG Air Single Valve (Includes Two (2) 3D Mesh Covers)
□
CGA1V2ICxxxx-x CG Air Single Valve (Includes Two (2) Incontinence Covers)
DUAL (2) VALVE
□
CGA2V2SCxxxx-x CG Air Dual Valve (Includes Two (2) Standard 2-way Stretch Covers)
□
CGA2V23Dxxxx-x CG Air Dual Valve (Includes Two (2) 3D Mesh Covers)
CG Air Dual Valve (Includes Two (2) Incontinence Covers)
SELECT CELL HEIGHT
CG Air Single Valve (Includes Two (2) Standard 2-way Stretch Covers)
□
CGA1V23Dxxxx-x
22" x 18" Qty: ______ 24" x 22" Qty: ______
□
2"
(Only available in Single Valve)
□
3"
□
4"
□
□
Other, specify __________ Qty: ______
22" x 20" Qty: ______ 24" x 24" Qty: ______
26" x 24" Qty: ______ 30" x 24" Qty: ______
30" x 20" Qty: ______ Other, specify __________ Qty: ______
30" x 22" Qty: ______
CGASCxxxx-x
CGA3Dxxxx-x
CGAICxxxx-x
Standard 2-way Stretch Cover. Specify Dimensions: W _____" D _____" H_____"
3D Mesh Cover. Specify Dimensions: W _____" D _____" H_____"
□
Incontinence Cover. Specify Dimensions: W _____" D _____" H_____"
□
□
CGAPK3 CG Air Patch Kit - 3 Patches (Includes alcohol prep pads and adhesive)
□
CGAPK15 CG Air Patch Kit - 15 Patches (Includes alcohol prep pads and adhesive)
MKT.F66
Specifications are subject to change without notice. Copyright @ 2020, Amylior Inc. (October 2020) Amylior CG Air - VA (Rev.3)
Page 1 of 3
CLEAR FORM
SEND BY EMAIL
DELUXE
CGAPK3 CG Air Patch Kit - 3 Patches (Includes alcohol prep pads and adhesive)
CGAPK15 CG Air Patch Kit - 15 Patches (Includes alcohol prep pads and adhesive)
24681012141618202224262830
2
4
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8
10
12
14
16
18
20
22
24
26
28
30
ORDERING INFORMATION: PHONE: (888) 453-0311, FAX: (877) 501-8458, EMAIL: info@amysystems.com
ACCOUNT INFORMATION
Fax Number:
User Name or Number:
VA (Billing):
Phone Number:
P.O. # or Quote:
Contact Name:
Zip Code:
CGADLX26+-23D
CGADLX26+-2IC
Email Address:
CG Air DELUXE - CUSTOM THERAPEUTIC SEAT CUSHION
14" to 20" WIDE
(Build as per specifications below)
Shipping Name:
Ship Address:
City:
State:
$680
CG Air Deluxe (Includes Two (2) 3D Mesh Covers) -
Below 22" Wide
(E2624) $800
CG Air Deluxe (Includes Two (2) Standard 2-way Stretch Covers) -
Below 22" Wide
(E2624)
□
□
CGADLX10-20-2SC
CGADLX10-20-23D
THE COLORS ARE USED TO SHOW THE DIFFERENT
CELL HEIGHT POSSIBILITIES
(E2624)
WIDTH - FRONT OF CUSHION
CG Air DELUXE - CUSTOM ORDER MATRIX
$705
22" to 24" WIDE
(Build as per specifications below)
□
CG Air Deluxe (Includes Two (2) Standard 2-way Stretch Covers) -
22" to 24" Wide
(E2625) $880
□
CGADLX10-20-2IC
CGADLX22-24-2SC
CG Air Deluxe (Includes Two (2) Incontinence Covers) -
Below 22" Wide
(E2625) $1,060
□
CG Air Deluxe (Includes Two (2) Incontinence Covers) -
22" to 24" Wide
(E2625) $925
CGADLX22-24-23D
CGADLX22-24-2IC
26" + WIDE
(Build as per specifications below)
□
CG Air Deluxe (Includes Two (2) Standard 2-way Stretch Covers) -
26" Wide or more
(E2625) $1,185
□
CG Air Deluxe (Includes Two (2) 3D Mesh Covers) -
22" to 24" Wide
□
CG Air Deluxe (Includes Two (2) 3D Mesh Covers) -
26" Wide or more
□
CG Air Deluxe (Includes Two (2) Incontinence Covers) -
26" Wide or more
DEPTH
CGADLX26+-2SC
$1,245
REPLACEMENT COMPONENTS
□
CGASCxxxx-x Standard 2-way Stretch Cover. Specify Dimensions: W _____" D _____" H_____" (E2619)
□
□
CGA3Dxxxx-x 3D Mesh Cover. Specify Dimensions: W _____" D _____" H_____" (E2619)
$130
$150
CGAICxxxx-x Incontinence Cover. Specify Dimensions: W _____" D _____" H_____" (E2619) $130
□
$31
□
$149
STEPS TO FOLLOW TO FILL OUT THE
MATRIX
1. Specify the requested size of the cushion
W ________" x D ________"
2. Specify the cell height ________". If
different heights are needed, indicate 2, 3 or
4 in each square to show each cell height.
3. Specifiy the number of valves as well as
the valve position by writing a "V". If more
than one valve is required, draw a line to
show the compartment area.
4. If cells are not required, indicate an "X" in
the square.
(VA) - October 2020
(E2625) $1,415
(E2625)
MKT.F66
Specifications are subject to change without notice. Copyright @ 2020, Amylior Inc. (October 2020) Amylior CG Air - VA (Rev.3)
Page 2 of 3
25" 12 24" 25" 14 24.5"
24" 12 24" 24" 13 22.75"
23" 11 22" 23" 13 22.75"
22" 11 22" 22" 12 21"
21" 10 20" 21" 12 21"
20" 10 20" 20" 11 19.25"
10 17.5"
19" 9 18" 19" 10 17.5"
17" 8 16" 17" 9 15.75"
16" 8 16" 16" 9 15.75"
15" 7 14" 15" 8 14"
14" 7 14" 14" 8 14"
10.50"
13" 6 12" 13" 7 12.25"
12"
SURFACE OF
CELLS
58.75"
11" 5 10" 11" 6 10.50"
WIDTH OR
DEPTH
# OF CELLS
SURFACE OF
CELLS
WIDTH OR
DEPTH
# OF CELLS
6 12" 12" 6
OTHER MANUFACTURERS
18" 9 18" 18"
10" 5 10" 10"
MEETS FLAMABILITY STANDARDS CAL TB 117-2013
www.amylior.com / info@amylior.com / Phone: 888 453-0311 / Fax: 877 501-8458
(VA) - October 2020
SIZING CHART
CG Air
MKT.F66
Specifications are subject to change without notice. Copyright @ 2020, Amylior Inc. (October 2020) Amylior CG Air - VA (Rev.3)
Page 3 of 3
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(E2622) $680 ACCOUNT INFORMATION CG Air Single Valve

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Completed 9 May 2021

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