NRG Gold Wheelchair Orderform

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NRG+ Gold Order Form

CLIENT INFORMATION

Customer Name: *

Purchase Order (Optional)

FRAME CONFIGURATION

Do you want Backrest? *

Yes

Do you want Cushion? *

Yes

Do you need Headrest? *

Yes

Do you want a Footbox?

Yes

Do you want a Tray? *

Yes

Choose Client Weight *

Up to 250Lbs (No Charge)

Choose Frame Color *

Black (No Charge)

Blue ($300)

Green ($300)

Burgundy ($300)

Gunmetal ($300)

Orange ($350)

Red ($350)

Pink ($350)

Purple ($350)

Yellow ($350)

Custom ($400)Custom ($400)

Seat Width *

14" Seat Width (No Charge)

15" Seat Width (No Charge)

16" Seat Width (No Charge)

17" Seat Width (No Charge)

18" Seat Width (No Charge)

19" Seat Width (WAMA) ($350.00)

20" Seat Width (WAMA) ($350.00)

Seat Depth *

14" Seat Depth ($350)

15" Seat Depth ($350)

16" Seat Depth (No Charge)

17" Seat Depth (No Charge)

18" Seat Depth (No Charge)

19" Seat Depth (WAMB) ($350.00)

20" Seat Depth (WAMB) ($350.00)

Seat Upholstery *

NU - Nylon (Black only) (No Charge)

VU - Vinyl (UBL - Black)

VU - Vinyl (UNB - Navy Blue) ($80)

VU - Vinyl (UBB - Light Blue) ($80)

Back Upholstery *

Omit (No Charge)

Nylon Back ($40)

Vinyl Back ($40)

Tension Adjustable Back - 14" to 18" (WAMD) ($159)

Tension Adjustable Back - Over 18" (WAME) ($189)

Back Height *

13.00"

13.75″

14.50″

15.25″

16.00″

16.75″

17.50″

18.25″

19.00" to 24.00" ($120.00)19.00" to 24.00" ($120.00)

SEAT HEIGHT CONFIGURATION

Choose Frame *

Hemi Frame (Seat Height Range: 12.50" to 17.00")

Standard Frame (Seat Height Range: 16.25" to 19.00")

Choose Rear Wheel - Hemi Frame *

20" (Diameter) X 1-3/8"(Tread Thickness)

22" (Diameter) X 1-3/8"(Tread Thickness)

24" (Diameter) X 1-3/8"(Tread Thickness)

Choose Rear Wheel - Standard Frame *

22" (Diameter) X 1-3/8"(Tread Thickness)

24" (Diameter) X 1-3/8"(Tread Thickness)

Choose Seat Height - 20" Wheel - Hemi Frame *

12.50" STF - 5" Caster - 2 Hole Fork

14.50" STF - 6" Caster - 3 Hole Fork

15.50" STF - 6" Caster - 5 Hole Fork

16.00" STF - 6" Caster - 5 Hole Fork

Choose Seat Height - 22" Wheel - Hemi Frame *

13.25" STF - 5" Caster - 3 Hole Fork

14.00" STF - 5" Caster - 3 Hole Fork

14.00" STF - 6" Caster - 3 Hole Fork

15.25" STF - 6" Caster - 5 Hole Fork

16.00" STF - 6" Caster - 5 Hole Fork

16.25" STF - 8" Caster - 5 Hole Fork

17.00" STF - 8" Caster - 5 Hole Fork

Choose Seat Height - 24" Wheel - Hemi Frame *

16.25" STF - 8" Caster - 5 Hole Fork

17.00" STF - 8" Caster - 5 Hole Fork

Choose Seat Height - 22" Wheel - Standard Frame *

16.25" STF - 6" Caster - 5 Hole Fork

17.25" STF - 6" Caster - 5 Hole Fork

18.00" STF - 6" Caster - 5 Hole Fork

17.50" STF - 8" Caster - 5 Hole Fork

18.25" STF - 8" Caster - 5 Hole Fork

19.00" STF - 8" Caster - 5 Hole Fork

Choose Seat Height - 24" Wheel - Standard Frame *

14.50" STF - 5" Caster - 2 Hole Fork

16.25" STF - 6" Caster - 3 Hole Fork

17.25" STF - 6" Caster - 3 Hole Fork

18.00" STF - 6" Caster - 5 Hole Fork

17.50" STF - 8" Caster - 5 Hole Fork

18.25" STF - 8" Caster - 5 Hole Fork

19.00" STF - 8" Caster - 5 Hole Fork

Choose Caster Type *

1-1/4" (Width) - No Charge

2" (Width) - Only 6" or 8" Sizes - $80.00

Choose Rear Wheel Type *

Spoke Wheels (Standard)

Mag Urethane - No Charge

Wheels Options

Quick Release Axle (WAMU) ($87.00)

Plastic Coated Handrim (WAMO) ($106.00)

One-Arm Drive System *

Yes

Choose Side for One-Arm Drive System *

Left Side (WAML) ($1100.00)

Right Side (WAML) ($1100.00)

*Only available on seat widths of 15" to 22" with 22" or 24" RW

WHEEL LOCK CONFIGURATION

Choose Wheel Lock *

Aluminium Push To Lock (No Charge)

Aluminium Pull To Lock (No Charge)

Steel Push To Lock (No Charge)

Steel Pull To Lock (No Charge)

Attendant Brakes ($240.00)

Unilateral Hand Brake - Left (WAMN) ($117.00)

Unilateral Hand Brake - Right (WAMN) ($117.00)

Wheel Lock Options *

6” Brake Extension (No Charge)

9” Brake Extension ($60.00)

ARM REST CONFIGURATION

Choose Armrest Type (No Charge) *

Flip Back

T Style

Choose Flip Back Armrest *

Flip Back - Full Length (Adjustable Height)

Flip Back - Desk Length (Adjustable Height)

Flip Back - Full Length (Adjustable Height Low)

Flip Back - Full Length (Non-Adjustable Height)

Flip Back - Desk Length (Non-Adjustable Height)

Choose T Style Armrest *

T Style - Full Length (Adjustable Height)

T Style - Desk Length (Adjustable Height)

T Style - Full Length (Adjustable Height Low)

T Style - Full Length (Non-Adjustable Height)

T Style - Desk Length (Non-Adjustable Height)

Armrest Accessories

Extra Wide Armpads ($182.00)

Extra Wide Gel Armpads ($312.00 )

FOOT REST AND FOOT PLATES CONFIGURATION

Legrest Type *

60° Plug Style (No Charge)

70° Plug Style (No Charge)

80° Plug Style (No Charge)

90° Plug Style ($180.00)

Elevating Legrest System (WAMK) ($380.00)

Footplate Type *

Angle Adjustable Footplates (WAMJ) ($240.00)

Plastic Footplates (No Charge)

Extra Large Footplates (SE0000322 x2) ($130.00)

Padded 1-Piece Footboard

Footplate/Legrest Options

Nylon Padded Leg Strap (SEFND0010) ($60.00)

Padded Footplates (SEFND0035 x2) ($86.00)

Amputee Support - Right (SEFND0005) ($246.00)

Amputee Support - Left (SEFND0005) ($246.00)

Split Padded Footboard (SEFND0015) ($95.00)

Footrest Impact Guards ($120.00)

Footrest Receiver Guards ($120.00)

FOOTBOX CONFIGURATION

Do you want footbox with composite frame? *

Yes

Choose Footbox (SEFND0020) ($207) *

Padded Footbox (1-Piece)

Padded Footbox (Split)

Footbox & Accessories

Contracture Sling (SEFND0020) ($240.00)

Padded Footbox - Right

Padded Footbox - Left

BACKREST CONFIGURATION & OPTIONS

NOTES:
All Backs Width Breakdown
Standard: 16"/18"/20"
Non-Standard: 14"/15"/17"/19"
Bariatric: 21" +

*ML Slim Height Breakdown
Standard: 18"
Tall: 20"
Short: 16"

Choose Backrest Model *

Fusion 1

Fusion 2

Fusion 3

Fusion Essential

Fusion ML Slim

Fusion ML Kyphotic

Fusion 1 Backrest *

Fusion 1 Standard (SE0001359) ($495.00)

Fusion 1 Non-Standard (SE0001360) ($564.00)

Fusion 1 Bariatric (SE0001361) ($633.00)

Fusion 1 - Back Height *

18" Back Height (Standard)

Custom (SEBND0015) ($47)Custom (SEBND0015) ($47)

Fusion 2 Backrest *

Fusion 2 Standard (SE0001584) ($460.00)

Fusion 2 Non-Standard (SE0001585) ($518.00)

Fusion 2 Bariatric (SE0001586) ($575.00)

Fusion 2 - Back Height *

18" Back Height (Standard)

Custom (SEBND0015) ($47)Custom (SEBND0015) ($47)

Fusion 3 Backrest *

Fusion 3 Standard (SE0001587) ($495.00)

Fusion 3 Non-Standard (SE0001588) ($564.00)

Fusion 3 Bariatric (SE0001589) ($633.00)

Fusion 3 - Back Height *

18" Back Height (Standard)

Custom (SEBND0015) ($47)Custom (SEBND0015) ($47)

Fusion Essential Backrest *

Fusion Essential Standard (SE0001362) ($695.00)

Fusion Essential Non-Standard (SE0001363) ($764.00)

Fusion Essential Bariatric (SE0001364) ($833.00)

Fusion Essential - Back Height *

18" Back Height (Standard)

Custom (SEBND0015) ($47)Custom (SEBND0015) ($47)

Fusion ML Slim Backrest *

Fusion ML Slim Standard (SE0001334) ($500.00)

Fusion ML Slim Short (SE0001336) ($525.00)

Fusion ML Slim Tall (SE0001335) ($525.00)

Fusion ML Slim Custom (SE0001337) ($600.00)

Fusion ML Kyphotic *

Standard Width - MLKST

Custom (SEBND0015) ($47)Custom (SEBND0015) ($47)

Fusion Essential Backrest Shell *

Shallow Shell

Deep Shell

Mid Shell

ML Kyphotic Backrest Shell *

Shallow Shell

Deep Shell

Mid Shell

Back Cover Material *

SpaceTek- Standard

Tek4 - Incontinent (Wipeable)

Reverse Tek4

CUSHION CONFIGURATION & OPTIONS

Choose Cushion Model

ML Cozy (ADP: SE0001090)

ML Extreme Comfort (ADP: SE0001091)

ML Bariatric (ADP: SE0001092)

ML CushionAir (ADP: SESGC0005)

ML CushionAir Bariatric (ADP: SESGC0010)

ML CushionAir Bariatric Plus (ADP: SESGC0015)

ML Cozy

Standard Sizes (*only available up to 20x20)

Custom Size (SESND1040) ($69)Custom Size (SESND1040) ($69)

CUSHION ADP: SE0001090

ML Extreme Comfort

Standard Sizes (*only available up to 20x20)

Custom Size (SESND1040) ($69)Custom Size (SESND1040) ($69)

CUSHION ADP: SE0001090

ML Bariatric

Standard Sizes

Custom Size (SESND1040) ($69)Custom Size (SESND1040) ($69)

CUSHION ADP: SE0001090

Cushion Cover Material *

SpaceTek- Standard

Tek4 - Incontinent (Wipeable)

Reverse Tek4

HEADREST CONFIGURATION

Choose Headrest Type

Omit

ML Multi Axis MAHF (SE0001133, SEHND0020, SEHND0010) ($460)

ML Adapt MAHF-A (SE0001133, SEHND0020, SEHND0010) ($500)

ML Contour MLCH (SE0001133, SEHND0020) ($265)

Headrest Cover

Reverse Tek4 - Standard (No Charge)

Tek4-Incontinent (Wipeable) (No Charge)

TRAY CONFIGURATION (ALL UPCHARGE)

Choose Full Tray (All ADP Approved)

Slide on Padded Tray Assembly - Standard Sizes ( SETND0005, SETND0035) ($280.00)

Slide on Padded Tray Assembly - Non Standard Sizes ( SETND0010, SETND0035) ($345.00)

Locking Padded Tray Assembly - Standard Sizes ( SETND0005, SETND0035) ($280.00)

Locking Padded Tray Assembly - Non Standard Sizes ( SETND0010, SETND0035) ($345.00)

Clear Plastic Tray(Lexan) (SETCF103L) ($362.00)

Choose Half Tray (All ADP Approved)

1/2 Lap Tray - Left Side (Padded) (SETND0015, SETND0035) ($268.00)

1/2 Lap Tray - Right Side (Padded) (SETND0015, SETND0035) ($268.00)

1/2 Clear Plastic Tray(Lexan) - Left Side (SETND0015) ($260.00)

1/2 Clear Plastic Tray(Lexan) - Right Side (SETND0015) ($260.00)

Choose Trough Tray (Includes 2 Elbow Stops) (SETND0015, SETND0035, 2x SETND0030))

1/2 Lap Tray - Left Side (Padded) ($380.00)

1/2 Lap Tray - Right Side (Padded) ($380.00)

Full Tray Elbow Stops (SETND0030)

Right Side ($56.00)

Left Side ($56.00)

Straight Front ($56.00)

Curved Corners ($56.00)

Curved Extended ($56.00)

ACCESSORIES

Choose Seat Belt (Upcharge) *

Auto Seat Belt ($23.00)

Padded Auto Seat Belt (SERND0030) ($56.00)

4-Point Padded Seat Belt (SERND0020) ($129.00)

Chest Harness (SERND0001) ($121.00)

Other Accessories

Transit Tie-Downs ($160.00) **Unoccupied** WC-19 - upto 250 lbs

Oxygen Tank Holder (WAMX) ($190.00)

I.V. Pole - Adjustable ($130.00)

I.V. Pole - Non-Adjustable ($110.00)

Choose Seating Accessories

Leg Bolster - 14"-18" (SESND1035) ($180.00)

Bariatric Leg Bolster over 18" (SESND1035) ($280.00)

Left Side Adductor (SEMCF702L, SEICF4011) ($177.00)

Right Side Adductor (SEMCF702L, SEICF4011) ($177.00)

Flip Down Pommel (SESND1043) ($259.00)

Cushion Rigidizer (SESND1015) ($80.00)

Back Cane Rigidizer ($120)

Raised Back Cane Rigidizer ($120)

Do you need dropbase? (SESND1020) ($216.00) *

Yes

Choose Dropbase Type

Solid Drop Base with Flush Mount

Solid Drop Base with w/Hooks

Additional Notes

Ordering Office/Store *

Mobility

Westin

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NRG Gold Wheelchair Orderform

CLIENT INFORMATION

FRAME CONFIGURATION

SEAT HEIGHT CONFIGURATION

WHEEL LOCK CONFIGURATION

ARM REST CONFIGURATION

FOOT REST AND FOOT PLATES CONFIGURATION

FOOTBOX CONFIGURATION

BACKREST CONFIGURATION & OPTIONS

CUSHION CONFIGURATION & OPTIONS

HEADREST CONFIGURATION

TRAY CONFIGURATION (ALL UPCHARGE)

ACCESSORIES

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