Edge 3 TB3 Order Form – Mobility Specialties Forms

CLIENT INFORMATION

Customer Name: *

PO#:

FRAME CONFIGURATION

Choose Frame Type *

Edge 3 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)

Accu-Trac Motor Technology – ($995)

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

Pretty in Pink

Choose Client Weight *

0 – 200 lbs

200 – 250 lbs

251 – 300 lbs

Seat Dimension – Width Package (Maximum width is 22″) *

12”-16″ Width Package

16”-20” Width Package

20”-24” Width Package

Seat Dimension – Depth Package (Maximum width is 22″) *

12”-16” Depth Package

16”-20” Depth Package

20”-24” 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

21″ Seat Width

22″ 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

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 ($285)

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

13″-19″ Extension, 5″x6″ Footplates

13″-19″ Extension, 5″x8″ Footplates

13″-19″ 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

NF-22, 50 Ah Gel Cell, MK Battery

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