Edge 3 Stretto TB3 Order Form – Mobility Specialties Forms

CLIENT INFORMATION

Customer Name: *

PO#:

FRAME CONFIGURATION

Choose Frame Type *

Edge 3 Stretto TB3 Seating ($8450)

Choose Seat Type *

TB3 Standard Tower Seat ($1045)

Tru Balance 3 12” Power Adjustable Seat Lift with iLevel ($2995)

Drive Motor Type *

6 mph Drive Motors (Standard)

Choose Frame Color *

Red Corvette

Back in Black

Night Train

Grey Street

Deep Purple

Raspberry Beret

Evolution Orange

Midnight Blue

Electric Blue

Blue Jean

Lemon Crush

Green Machine

Military Green

Choose Client Weight *

0 – 200 lbs

201 – 300 lbs

Seat Dimension – Width Package (Maximum width is 20″) *

12”-16″ Width Package

16”-20” Width Package

Seat Dimension – Depth Package (Maximum width is 20″) *

12”-16” Depth Package

16”-20” Depth Package

Seat Width *

14″ Seat Width

15″ Seat Width

16″ Seat Width

17″ Seat Width

18″ Seat Width

19″ Seat Width

20″ Seat Width

Seat Depth *

14″ Seat Width

15″ Seat Width

16″ Seat Width

17″ Seat Width

18″ Seat Width

19″ Seat Width

20″ Seat Width

Seat to Floor Height *

Lowest (16.5″)

Middle (17.5″)

Highest (18.5″)

Back Cane Height *

16” High Canes

17” High Canes

20” High Canes

21” High Canes

24” High Canes

25” High Canes

Standard Lap Belts *

38” Lap Belt

50” Lap Belt

60” Lap Belt

70” Lap Belt

80” Lap Belt

90” Lap Belt

Drive Wheels *

3”x14” Flat Free Black Tires (Standard)

3”x14” Pneumatic Black Tires (No Charge)

3”x12.5” Flat Free Black Tires (No Charge)

3”x12.5” Pneumatic Black Tires (No Charge)

JOYSTICK CONFIGURATION

Choose Controller *

QLNES (Standard)

Q-Logic 3 E ($620)

Q-Logic 3 ($900)

Joystick Mounting Bracket *

Fixed, In-line, Bracket – (Standard)

Adjustable Swing Away – ($265)

Offset Swing Away – ($265)

Basic Swing Away – ($265)

Joystick Mounting Side *

Left Side Mount

Right Side Mount

Joystick Handles (optional)

Mushroom Handle (A) – ($120)

Chin Cup (B) – ($90)

T-Bar (C) – ($160)

Medium Ball Handle (D) – ($70)

Soft Ball Handle (E) – ($120)

Extended I-Handle (F) – ($140)

3” Goal Post Handle – ($180)

4” Goal Post Handle – ($180)

ARM REST CONFIGURATION

Left Armrest Type *

Two-Post, Flip Back, Height Adjustable, Removable Armrests – Full Length

Two-Post, Flip Back, Height Adjustable, Removable Armrests – Desk Length

Single Post, Heavy Duty, 8″-12″ Height Adjustable, Drop In Armrests – Full Length

Single Post, Heavy Duty, 8″-12″ Height Adjustable, Drop In Armrests – Desk Length

Single Post, Heavy Duty, 10″-14″ Height Adjustable, Drop In Armrests – Full Length

Single Post, Heavy Duty, 10″-14″ Height Adjustable, Drop In Armrests – Desk Length

Right Armrest Type *

Two-Post, Flip Back, Height Adjustable, Removable Armrests – Full Length

Two-Post, Flip Back, Height Adjustable, Removable Armrests – Desk Length

Single Post, Heavy Duty, 8″-12″ Height Adjustable, Drop In Armrests – Full Length

Single Post, Heavy Duty, 8″-12″ Height Adjustable, Drop In Armrests – Desk Length

Single Post, Heavy Duty, 10″-14″ Height Adjustable, Drop In Armrests – Full Length

Single Post, Heavy Duty, 10″-14″ Height Adjustable, Drop In Armrests – Desk Length

Armpads Type *

Straight Armpads

Waterfall Armpads

LEGREST CONFIGURATION

Foot Platform Type *

Base Mounted Foot Platform (No Charge)

Manually Adjustable Center Mount Foot Platform ($265)

Swing-Away Legrest

CENTER MOUNT FOOT CONFIGURATION

Lower Extension and Footplates *

10″-16″ Extension, 5″x6″ Footplates

10″-16″ Extension, 5″x8″ Footplates

10″-16″ Extension, 5″x11″ Footplates

Center Mount Calf Support (optional)

Small Calf Pads (pair) 6”Wx6”H – ($210)

Large Calf Pads (pair) 8” taper to 6”Wx8”H – ($210)

Modular Footplate Extension Components (optional)

Width Extension (pair) – ($55)

Outside Edge (pair) – ($55)

SWING AWAY LEGREST SPECIFICATIONS

Left Side Swing Away Legrest *

60°-90° Swing-Away Legrest – ($285)

60°-90° Swing-Away Legrest, Short – ($285)

Right Side Swing Away Legrest *

60°-90° Swing-Away Legrest – ($285)

60°-90° Swing-Away Legrest, Short – ($285)

Left Legrest Lower Extension *

11”-13” Length

13”-16.5” Length

15.5”-19.5” Length

Right Legrest Lower Extension *

11”-13” Length

13”-16.5” Length

15.5”-19.5” Length

Angle Adjustable Footplate(s) *

5”Wx8”D – ($87.50 Each)

6”Wx8”D – ($87.50 Each)

6”Wx11”D – ($87.50 Each)

8”Wx11”D – ($87.50 Each)

BATTERIES SPECIFICATIONS

Choose Batteries *

NF-22, 55 Ah Gel Cell, Interceptor Battery ($300 Each)

40 Ah Gel Cell, Interceptor Battery ($200 Each)

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