Fillable M1 Dealer Information * Indicates a Required Field (Accident Compensation Corporation New Zealand)

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M1 Dealer Information * Indicates a Required Field (Accident Compensation Corporation New Zealand)

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PO#:
_____________________________
_
* Shipping Location:______________________________
Address:
_____________________________
_
* Phone#:_____________________________
_
* Contact:_____________________________
_
* City:_____________________________
_
* Fax#:_____________________________
_
* Weight:______________________________
_
*Height:______________________________
_
A) Top of Shoulders:
______________________________
_
B) Chest Depth:
______________________________
_
C) Chest Width:
______________________________
_
D) Seat Depth:
______________________________
_
E) Top of Head:
______________________________
_
F) Elbow to Hand:
______________________________
_
G) Seat Pan to Elbow:
______________________________
_
H) Hip Width:
______________________________
_
*I) Knee to Foot:______________________________
Permobil New Zealand Ltd
181A McLeod Rd, Te Atatu South,
Auckland 0610, New Zealand
0800 115 222
permobil.com/en-nz
* State
:
_____________________________
_
Diagnosis:
_____________________________
_
Permobil recommends that the client is evaluated by a
certified rehab specialist.
Dealer Information
Client Information
Client Measurements
Funding Source:
_____________________________
_
Prices effective: April 01, 2018
Client Age:
_____________________________
_
Company Code:______________________________
* First Name:_____________________________
_
* Indicates a Required Field
* Last Name:_____________________________
_
Email Address:
_____________________________
_
M1
PERMNZ
M1
Chair Model and Colors
M1 Base I108006-99-0
Price Includes: MWD M1 Power Base Set Up For Power Tilt, FlexLink Suspension System, 7"
Flat Free Casters, Tie-Down Hardware for Strap Systems and Charger. Max Speed = 8kmh,
Weight Capacity = 136kg, STFH = 16".
CHOOSE DRIVE TIRES:
DescriptionPart Numbe
r
Flat Free Tire 3"W x 14"T - BlackI107974-99-0
No Charge
Pneumatic Tire 3"W x 14"T - BlackI107975-99-0
No Charge
OPTIONAL DRIVE TIRES:
DescriptionPart Numbe
r
Pneumatic/Snow Tire 3"W x 14"T BlackI107976-99-0
CHOOSE SHROUD COLOR
:
DescriptionPart Numbe
r
M1 Color Kit - Sunburst OrangeI107967-99-0
No Charge
M1 Color Kit - Galactic GreenI107968-99-0
No Charge
M1 Color Kit - Midnight BlackI107969-99-0
No Charge
M1 Color Kit - Ocean BlueI107970-99-0
No Charge
M1 Color Kit - Power PinkI107971-99-0
No Charge
M1 Color Kit - Radiant RedI107973-99-0
No Charge
M1 Color Kit - Mossy Oak Break-Up CountryI108205-99-0
M1 Color Kit - Carbon FiberI108206-99-0
M1 Color Kit - CDG PolyI108207-99-0
Base Options
CHOOSE ONE OF THE FOLLOWING:
DescriptionPart Numbe
r
PLEASE NOTE:
A
dditional parts are required to change the seat to floor height in the field.
Seat to Floor Height - 16"I108021-99-0
No Charge
Seat to Floor Height - 17"I108022-99-0
No Charge
Seat to Floor Height - 18"I108023-99-0
No Charge
MUST CHOOSE BATTERIES:
DescriptionPart Numbe
r
Batteries, Grp 34 (60Ah) Sealed Gel, x2, InstalledI107032-99-0
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Enhanced Steering Perform Unit (ESP), R-netI107998-99-0
Joystick Options
CHOOSE JOYSTICK TYPE:
DescriptionPart Numbe
r
Permobil Joystick Module I108319-99-0
Designed exclusively for Permobil, this R-net color joystick features: control of up to 4
Bluetooth devices, Infrared control, programmable buttons and a programmable switch jack; al
l
in a compact, durable Aluminum housing.
R-net LED Remote JoystickI108289-99-0
No Charge
This Joystick does NOT have a Display Screen and does NOT contain mono jacks. Limited to
five profiles with this Joystick Module.
Pa
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Rev 2018-2 04/01/2018
M1
Joystick Options
CHOOSE JOYSTICK HANDLE TYPE:
DescriptionPart Numbe
r
Cone Shaped Joystick Knob - StandardI10045
No Charge
Chin Cup For Joystick KnobI100960-99-0
"T" Handle For Joystick KnobI100961-99-0
"Large Ball" For Joystick KnobI100962-99-0
"Softball" For Joystick KnobI100963-99-0
"Mushroom" For Joystick KnobI100964-99-0
"Stick" For Joystick KnobI100965-99-0
1.75" Black Foam Ball For Joystick KnobI105442-99-0
Bodypoint J/S Handle 3" U-Shaped w/ Flex-ShaftI105846-99-0
Bodypoint J/S Handle 4" U-Shaped w/ Flex-ShaftI105847-99-0
Bodypoint J/S Handle Dome Shaped, RubberI105848-99-0
CHOOSE JOYSTICK MOUNT:
DescriptionPart Numbe
r
Joystick Mount Right - FixedI11216
No Charge
Joystick Mount Left - FixedI11217
No Charge
Slimline Retractable Joystick Mount - RightI108037-99-0
Slimline Retractable Joystick Mount - LeftI108038-99-0
Adjustable Height Panel BracketI11232
Provides 1.77" of vertical adjustment below the armrest and 25° of angle adjustment.
Compatible with all Permobil joystick mounts except for the M1 Fixed Joystick Mount.
Mount Standard JS on Back Cane as Attendant ControlI108311-99-0
Attendant Control R-Net for 1" Diameter TubeI108312-99-0
Seating System
CHOOSE ONE OF THE FOLLOWING:
DescriptionPart Numbe
r
50° Power Tilt - M1 I107978-99-0
Backrest angle can be manually adjusted up to 110°. A 1/2 speed limitation is applied when th
e
tilt angle is > or = to 20°.
EZ Fold Backrest I108185-99-0
This feature allows the tubular backrest frame to be easily folded forward to reduce the
transport height of an unoccupied wheelchair.
Seating System Options
CHOOSE SEAT FUNCTION CONTROL TYPE:
DescriptionPart Numbe
r
Seat Function Control - No ChargeI11239
No Charge
Backrest Options
CHOOSE TUBULAR BACKREST FRAME:
DescriptionPart Numbe
r
PLEASE NOTE:
Tubular Backrest features 1" diameter back canes. The Tubular Backrest Frame and the
Backrest Width Must match the Seat Width. The Backrest cane height is 20" from the seat pan
to the bend of the canes.
Tubular Backrest Frame - 14"WI107985-99-0
No Charge
Tubular Backrest Frame - 16"WI107986-99-0
No Charge
Pa
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Rev 2018-2 04/01/2018
M1
Backrest Options
CHOOSE TUBULAR BACKREST FRAME:
DescriptionPart Numbe
r
Tubular Backrest Frame - 18"WI107987-99-0
No Charge
Tubular Backrest Frame - 20"WI107988-99-0
No Charge
Tubular Backrest Frame - 22"WI107989-99-0
No Charge
CURVED, SOLID BACKREST OPTIONS:
DescriptionPart Numbe
r
PLEASE NOTE:
The Curved, Solid Backrests will come with a leatherette backrest cushion. The backrest shell
will be set 3" above the seat pan.
Curved, Solid Backrest - 14"W x 16"TI108086-99-0
No Charge
Curved, Solid Backrest - 16"W x 20"TI108085-99-0
No Charge
Curved, Solid Backrest - 18"W x 20"TI108087-99-0
No Charge
Curved, Solid Backrest - 20"W x 20"TI108088-99-0
No Charge
Curved, Solid Backrest - 22"W x 20"TI108089-99-0
No Charge
Omit Backrest I11231
No Charge
Seat Sizing
CHOOSE SEAT WIDTH:
DescriptionPart Numbe
r
PLEASE NOTE:
The Seat Width is available in 2" increments from 14"-22" and is not adjustable without
additional parts. Please select Seat Width below. The seat width must match the backrest
width.
Set Seat Width at 14" I107980-99-0
No Charge
Set Seat Width at 16" I107979-99-0
No Charge
Set Seat Width at 18" I107982-99-0
No Charge
Set Seat Width at 20" I107981-99-0
No Charge
Set Seat Width at 22" I107984-99-0
No Charge
CHOOSE SEAT DEPTH:
DescriptionPart Numbe
r
PLEASE NOTE:
The Seat Depth is adjustable from 14"-22" in 1" increments without additional parts. Please
select the Seat Depth below.
Set Seat Depth at 14" I107991-99-0
No Charge
User weight cannot exceed 165lbs.
Set Seat Depth at 15" I107992-99-0
No Charge
Set Seat Depth at 16" I107993-99-0
No Charge
Set Seat Depth at 17" I107994-99-0
No Charge
Set Seat Depth at 18" I107995-99-0
No Charge
Set Seat Depth at 19" I107996-99-0
No Charge
Set Seat Depth at 20" I107997-99-0
No Charge
Set Seat Depth at 21" I108028-99-0
No Charge
Set Seat Depth at 22" I108029-99-0
No Charge
Armrest Options
CHOOSE ONE OF THE FOLLOWING:
DescriptionPart Numbe
r
Pa
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Rev 2018-2 04/01/2018
M1
Armrest Options
CHOOSE ONE OF THE FOLLOWING:
DescriptionPart Numbe
r
PLEASE NOTE:
The Low Mount Armrest Assembly can be adjusted from 7"-12" from the seat pan. The High
Mount Armrest Assembly can be adjusted from 10"-14" from the seat pan. Please select the
High or Low Mount Armrest Assembly and Armrest Height below.
Locking Flip Back Height Adj Armrests - HighI11225
No Charge
Locking Flip Back Height Adj Armrests - LowI11226
No Charge
SET ARMREST HEIGHT AT:______
CHOOSE ARMREST PAD RIGHT:
DescriptionPart Numbe
r
4"x10" Corpus Armrest Pad Right - LeatheretteI105100-99-0
No Charge
4"x13" Corpus Armrest Pad Right - LeatheretteI105104-99-0
No Charge
4"x10" Corpus Arm w/ Stealth Gel Pad - RightI106486-99-0
4"x13" Corpus Arm w/ Stealth Gel Pad - RightI106488-99-0
2"x10" Narrow Armrest Pad - RightI108091-99-0
No Charge
2"x14" Narrow Armrest Pad - RightI108092-99-0
No Charge
CHOOSE ARMREST PAD LEFT:
DescriptionPart Numbe
r
4"x10" Corpus Armrest Pad Left - LeatheretteI105098-99-0
No Charge
4"x13" Corpus Armrest Pad Left - LeatheretteI105102-99-0
No Charge
4"x10" Corpus Arm w/ Stealth Gel Pad - LeftI106487-99-0
4"x13" Corpus Arm w/ Stealth Gel Pad - LeftI106489-99-0
2"x10" Narrow Armrest Pad - LeftI108090-99-0
No Charge
2"x14" Narrow Armrest Pad - LeftI108093-99-0
No Charge
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Armrest Pouch - Right I107339-99-0
Armrest Pouch - Left I107338-99-0
UT Armrest Side Support - Right OuterI107840-99-0
Includes 2"T x 6.5"W tapered pad.
UT Armrest Side Support - Left OuterI107863-99-0
Includes 2"T x 6.5"W tapered pad.
UT Armrest Side Support - Right InnerI107864-99-0
Includes 2"T x 6.5"W tapered pad. May require an increase to the width between the armrests
to ensure armrests will flip-up.
UT Armrest Side Support - Left InnerI107865-99-0
Includes 2"T x 6.5"W tapered pad. May require an increase to the width between the armrests
to ensure armrests will flip-up.
UT Elbow Support - RightI107839-99-0
Must also select PN I10881.
UT Elbow Support - LeftI107838-99-0
Must also select PN I10882.
Adjustable Elbow Support Hardware - RightI10881
Adjustable Elbow Support Hardware - LeftI10882
Legrest Options
CHOOSE LEGREST OPTIONS:
DescriptionPart Numbe
r
Manual Elevating Legrest - Center MountI108015-99-0
No Charge
Page 5 of 11
Rev 2018-2 04/01/2018
M1
Legrest Options
CHOOSE ONE OF THE FOLLOWING:
DescriptionPart Numbe
r
2pc Narrow Footplates - 8.5"D x 5.5"W, ShortI108212-99-0
No Charge
Footplate height range, 7-12.5"
2pc Narrow Footplates - 8.5"D x 5.5"W, LongI108094-99-0
No Charge
Footplate height range, 11-16"
2pc Wide Footplates - 9"D x 7.5"WI108156-99-0
Footplate height range, 11-16" Risk of caster interference possible. Legrest angle must be
adjusted to ensure footplates clear casters while driving.
SET FOOTPLATE HEIGHT AT:______
This is measured from the SEAT PAN to the top of the FOOTPLATE, when the legrest
assembly is at 90°. Do NOT include cushion thickness in your measurement. In one inch
increments, please indicate desired footplate height. NOTE: The footplate height must be set
at least 2" less than the seat height. Height may need to be reduced for shipping.
CHOOSE ONE OF THE FOLLOWING:
DescriptionPart Numbe
r
UT Calf Support Kit (B) w Mesh Cover & Adj HardwareI108203-99-0
No Charge
3.5"W x 4.5"T Pad.
UT Calf Support Kit (J) w Mesh Cover & Adj HardwareI108200-99-0
No Charge
5"W x 6.5"T Pad.
UT Calf Support Kit (A) w Mesh Cover & Adj HardwareI108204-99-0
No Charge
5.5"W x 6"T Pad.
UT Calf Support Kit (H) w Mesh Cover & Adj HardwareI108201-99-0
7"W x 7"T Curved Pad.
UT Calf Support Kit (D) w Mesh Cover & Adj HardwareI108202-99-0
8"W x 8"T Pad.
Accessories
MUST CHOOSE POSITIONING BELT:
DescriptionPart Numbe
r
Positioning Belt I100518-99-0
No Charge
CHOOSE ONE OF THE FOLLOWING:
DescriptionPart Numbe
r
Permobil 7"W Headrest w/ Link HardwareI107470-99-0
Must also select I107480-99-0 or I107481-99-0.
Permobil 10"W Headrest w/ Link HardwareI107469-99-0
Must also select I107480-99-0 or I107481-99-0.
Permobil 14"W Headrest w/ Link HardwareI107468-99-0
Must also select I107480-99-0 or I107481-99-0.
Adj/Removable Headrest Link Hardware - StandardI107480-99-0
Adj/Removable Headrest Link Hardware - ExtendedI107481-99-0
Includes an additional 3" link to extend headrest pad range.
OPTIONAL ITEMS:
DescriptionPart Numbe
r
UT Amp. Support Pad (H) w/ Mesh Cover - (1 Each)I103070-99-0
7"W x 7"T Curved Pad. Must also select PN I10553.
UT Amp. Support Pad (D) w/ Mesh Cover - (1 Each)I103071-99-0
8"W x 8"T Flat Pad. Must also select PN I10553.
Adj Removable - Amp Support Hardware (1 Each)I10553
Please indicate if you would like the amputation support mounted on the right or left side of the
seat frame:
Mount Amp Suppt on Left: _____ Mount Amp Suppt on Right: _____
Page 6 of 11
Rev 2018-2 04/01/2018
M1
Accessories
OPTIONAL ITEMS:
DescriptionPart Numbe
r
UT Hip Suppt (B) w/ Mesh Cover - High (Pair)I106104-99-0
4.5"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.
UT Hip Suppt (A) w/ Mesh Cover - High (Pair)I106103-99-0
6"W x 5.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.
UT Thigh/Hip Suppt (J) w/ Mesh Cover - High (Pair)I103094-99-0
6.5"W x 5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.
UT Thigh/Hip Suppt (C) w/ Mesh Cover - High (Pair)I103095-99-0
8"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.
UT Thigh/Hip Suppt (G) w/ Mesh Cover - High (Pair)I102977-99-0
12"W x 3.5"T Pad w/ 4" Tall Mounting Bracket. Must also select PN I10550.
Adj Removable - Thigh Support Hardware (Pair)I10550
Transfer Handles, Corpus SeatI105260-99-0
Repositioning Handles for 1" Diameter TubeI108336-99-0
RAM Self-Leveling Cup HolderI106210-99-0
RAM X-Grip Phone Holder I106806-99-0
RAM X-Grip 10" Tablet Holder w/Swing Away MountI107100-99-0
Compatible with most 10" screen tablets with or without a protective case. Includes adjustable
swing away mount (I103476-99-0). Note: Customization may be required if ordered along with
an Omni.
Medical Necessities Bag HooksI105805-99-0
Please Note: Recline is limited to 165° or less (depending on backrest height) when ordering
with 23" or 24" tall Ergo backrest. Custom required if ordered with a ROHO AGILITY backrest.
Medical Necessities Bag I102059-99-0
Includes hardware to attach bag to backrest. Please Note: Recline is limited to 165° or less
(depending on backrest height) when ordering with a 23" or 24" tall Ergo backrest. Custom
required if ordered with a ROHO AGILITY backrest.
Small Angle Adjustable TrayI10843
Must also select PN I10556.
Mount on Left: _____ Mount on Right: _____
Adj Removable - Tray Hardware (1 Each)I10556
Crutch Holder for 1" Diameter TubeI108107-99-0
O2 Holder for 1" Diameter TubeI108106-99-0
Alternative Drive Systems
A
LTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:
DescriptionPart Numbe
r
Mini-Joystick for Omni - (9-pin connector)I10751
Operating Force = 13 g Neutral to Full Deflection = 5mm
Compact Joystick for Omni - (9-pin connector)I103893-99-0
Operating Force = 220 g Neutral to Full Deflection = 28mm Joystick includes two 3.5mm
mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam
Ball Knob.
Compact Joystick LITE for Omni - (9-pin connector)I103894-99-0
Operating Force = 50 g Neutral to Full Deflection = 17mm Joystick includes two 3.5mm mono
j
acks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball
Knob.
A
LT PROPORTIONAL JOYSTICK MOUNTING HARDWARE:
DescriptionPart Numbe
r
NOTE:
Please see the PERMOfix Mounting Solutions, within the Alt Drive Accessories section, for
additional mounting options.
Page 7 of 11
Rev 2018-2 04/01/2018
M1
Alternative Drive Systems
A
LT PROPORTIONAL JOYSTICK MOUNTING HARDWARE:
DescriptionPart Numbe
r
Alt. JS Swing Away Mount Kit - ArmrestI104690-99-0
Mount in front of Left Arm: _____ Mount in front of Right Arm: _____
Alt JS/Omni Combo Swing Away Mount Kit - ArmrestI107135-99-0
Used to mount Omni and Alternative Proportional Joystick to the same armrest. Includes
Swing Away Omni/Tablet Mount, with a longer mounting rod, two PERMOfix modules, one 3"
rod and one 4" rod.
Mount in front of Left Arm: _____ Mount in front of Right Arm:_____
Alt. JS Adjustable Mount Kit - MidlineI104695-99-0
Mount on Left Arm: _____ Mount on Right Arm: _____
Haims Harness for Chin Control Mount, LargeI10752
For neck width up to 19cm.
Haims Harness for Chin Control Mount, SmallI10753
For neck width up to 14cm.
A
LT PROPORTIONAL JOYSTICK ACCESSORIES:
DescriptionPart Numbe
r
Dual Switches for Compact Joystick - Fixed MountI104904-99-0
Includes two pushbutton switches mounted on rigid Switches can be used for Mode & On/Off.
Switch operation force = 130 g.
Mount at front of Joystick: _____ Mount at rear of Joystick: _____
Mount at left of Joystick: _____ Mount at right of Joystick: _____
Dual Switches for Compact Joystick - Gooseneck MntI104641-99-0
Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches are
p
ositioned on Left and Right sides of Compact Joystick. Switches can be used for Mode &
On/Off. Switch operation force = 130 g
SIP & PUFF SYSTEMS:
DescriptionPart Numbe
r
Sip & Puff System for OmniI10573
Requires Omni Control Module. Includes breath tube kit.
Sip & Puff System with Fiber Optic Opti-StopI10574
Requires Omni Control Module. Includes breath tube kit.
Sip & Puff Kit for Total Control Head ArrayI106807-99-0
For use with Total Control Head Array. Requires Omni Control Module. Includes breath tube
kit.
Adjustable Mounting Hrdw - Sip & PuffI10762
Required when selecting PN I10573, I10574 or I106807-99-0.
Total Control Head Array
CONFIGURE HEAD ARRAY:
DescriptionPart Numbe
r
Permobil Head Array - 3-Switch SystemI106805-99-0
Features an occipital pad sensor and two stainless steel arms configured with proximity
sensors. The arms are mounted to the upper attachment points on the head array. Longer
arms are also included to extend the sensor adjustment range. ESP recommended. Choose
Omni Control Module (ID51154IR) separately.
Program Head Array as a 5-Switch SystemI11072
No Charge
Select additional arms/sensors below and indicate the intended use of each sensor in the
Notes & Comments section. Choose Omni Control Module (ID51154IR) separately.
CHOOSE OCCIPITAL PAD SIZE (REQUIRED):
Small Occipital Pad for Head Array - 4.25"W x 3"HI105920-99-0
No Charge
Large Occipital Pad for Head Array - 6"W x 4"HI105921-99-0
No Charge
.
Page 8 of 11
Rev 2018-2 04/01/2018
M1
Total Control Head Array
CONFIGURE HEAD ARRAY:
DescriptionPart Numbe
r
CHOOSE OCCIPITAL PAD MOUNT (REQUIRED):
Fixed Mount for Occipital Pad - Head ArrayI10847
No Charge
Adj. Swivel Mount for Head Array Occipital PadI105936-99-0
Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms.
CHOOSE HEAD ARRAY MOUNT HARDWARE (REQUIRED):
Stealth TWB480 Backrest Mounting Hdwr with LinksI105927-99-0
Please select the length of the vertical stem below:
Standard length (10"): _____ Short length (6"): _____
Stealth TWB480 Backrest Mtng Hdwr with FlipbackI105941-99-0
Stealth HMO475 Backr Mtng Hdwr w 17mm BallI105925-99-0
Stealth TWB480 Backrest Mnt Hdwr w SubOcptl MountI106319-99-0
Stealth 600 SubOccipital Pad - 8.5"W x 2.75"HI106282-99-0
Must select when PN I106319-99-0 is ordered.
SELECT ADDITIONAL LEFT ARM PACKAGE (OPTIONAL):
Add Left Lateral Arm w Proximity SensorI10976
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Left Lateral Arm w Egg SwitchI10977
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Left Lateral Arm w Pad (No Sensor or Switch)I10978
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
SELECT ADDITIONAL RIGHT ARM PACKAGE (OPTIONAL):
Add Right Lateral Arm w Proximity SensorI10979
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Right Lateral Arm w Egg SwitchI10980
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Right Lateral Arm w Pad (No Sensor or Switch)I10981
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Alt Drive Systems Setup
CHOOSE OMNI
(
REQUIRED
)
:
DescriptionPart Numbe
r
Omni Control Module for R-net w/ InfraredID51154IR
Must also select mounting hardware, either I103476-99-0 or I107135-99-0. Please specify
which type of alternative drive input you will be using if not ordering it from Permobil.
Input Device: ___________________________
Adjustable Swing-Away Hardware - Omni/TabletI103476-99-0
Mount in front of Left Arm: _____ Mount in front of Right Arm: _____
Alt Drive Accessories
PERMOFIX MOUNTING SOLUTIONS:
DescriptionPart Numbe
r
PERMOfix UniTrack Fixed Mount KitI106655-99-0
Includes two base joints, two 4" rods and one 8" rod.
Page 9 of 11
Rev 2018-2 04/01/2018
M1
Alt Drive Accessories
PERMOFIX MOUNTING SOLUTIONS:
DescriptionPart Numbe
r
PERMOfix UniTrack Removable Mount KitI106656-99-0
Includes quick release mount and thigh support hardware, two base joints and three different
length rods.
PERMOfix UniTrack Swing Away Mount KitI106657-99-0
Includes PERMOfix Swing Away module, two base joints, one 2" rod and one 4" rod.
Proximity Sensor + Swivel Assm - Not MountedI105907-99-0
Only available with the Total Control Head Array. Swivel assembly allows sensor to be
mounted with PERMOfix or directly to lateral arm of Total Control Head Array. Since Proximity
Sensors require power, they CANNOT be used as On/Off switches.
Egg Switch + Swivel Mount Assm - Not MountedI105919-99-0
Swivel assembly allows switch to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
Solid Lateral Pad+Swivel Joint - Not MountedI105912-99-0
Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
Oval Plate + Swivel Assm - No Switch - Not MountedI106675-99-0
Blank plate provides mounting option for Micro Lite, Buddy Button or other switch options.
Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Micro Lite Switch Qty:____I101769-99-0
Buddy Button Qty:____I101767-99-0
Egg Switch Black Qty: _____I106293-99-0
Mini Cup Switch Qty:____I101771-99-0
Proximity Switch Qty:____I107500-99-0
Mini Joyswitch 5 Switch OC for Omni - (9-pin)I107495-99-0
Touch Contact with CR2032 Battery Qty:____I107498-99-0
Dome Switch, Backrest Mnt w Gooseneck Qty: _____I10772
Mount on Left: _____ Mount on Right: _____
Mounts at top of backrest shell. Custom charge may be applied if ordering with short backrest
heights. Kit Includes: One PERMOfix joint with Flat Plate, two PERMOfix joints with 45° swivel
adjustment, one 150mm rod, one 200mm rod and one 225mm gooseneck switch with 1.2m
cable and mounting clamp.
Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty:____I10846
Mount on Left: _____ Mount on Right: _____
w 90° Swing-Away Function. Mounts at top of back. Custom charge applies if ordered with
short back. Kit Includes: One PERMOfix joint with Flat Plate, one PERMOfix joint with 45°
swivel adjustment, two 6" rods, one 90° Swing-Away joint, one 9"
3.5mm Ext. Cable for Sensor/Switch, 0.3m LongI105935-99-0
3.5mm Ext. Cable for Sensor/Switch, 1m LongI105931-99-0
3.5mm Ext. Cable for Sensor/Switch, 2m LongI105932-99-0
3.5mm Ext. Cable for Sensor/Switch, 3m LongI105933-99-0
3.5mm Y-splitter Cable for Sensor/SwitchI105934-99-0
A
llows two Proximity Sensors/Mechanical Switches to connect to the same direction jack.
Page 10 of 11
Rev 2018-2 04/01/2018
Chair Order Policy:
You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms. The order cannot be processed
without the following:
-A client name or code, the client’s measurements, the client’s weight
-The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil is no
t
responsible for configuration or size discrepancies resulting from customer errors on the order form.
-Order confirmations will be provided by Permobil 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.
Order Acknowledgement:
I, _________________________, am an agent of the medical equipment provider named on this order form and I have the authority to contract for the
purchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete and
accurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returns policy
and may carry additional charges.
Signed:
Printed Name:
Title:
Date:
NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if ordered with the wheelchair. Any
parts ordered for service or future alterations will carry different pricing and warranty.
Additional Order Instructions:
Page 11 of 11
Rev 2018-2 04/01/2018
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Completed 16 January 2022

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