(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)
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