STP Wheelchair Orderform – Mobility Specialties Forms

CLIENT INFORMATION

Customer Name (Required)

Purchase Order Number (Optional)

FRAME CONFIGURATION

Choose Frame Color Choose Frame Color

Choose Client Weight

Seat Width Seat Width

Seat Depth Seat Depth

Seat to Floor Height

Choose Front Casters

Choose Rear Wheels

Rear Wheels Options

Axles – Quick Release (WAMU) ($120.00)

Narrow Handrim Config. (1/2" less) (No Charge)

WHEEL LOCK CONFIGURATION

Dropdown

Wheel Lock Options

4” Brake Extension (No Charge)

6” Brake Extension (No Charge)

9” Brake Extension (Upcharge)

ARM REST CONFIGURATION

Choose Armrest Type

FOOT REST AND FOOT PLATES CONFIGURATION

Legrest Type

Footplate Type

Plastic Footplates (No Charge)

Extra Large Footplates (SE0000322) ($150.00)

Angle Adjustable Footplates (WAMJ) ($240.00)

One Piece Foot Board (SEFND0015) ($80.00)

Footplate/Legrest Options

One Piece Foot Board Padding (SEFND0035) ($44.00)

Contracture Sling - Standard (SEFND0020) ($240.00)

Contracture Sling - M Style (SEFND0020) ($240.00)

Nylon Leg Strap Padded (SEFND0010) ($60.00)

Nylon Leg Strap Custom (SEFCF107L) ($120.00)Nylon Leg Strap Custom (SEFCF107L) ($120.00)

HEADREST CONFIGURATION

Choose Multi-Axis Headrest Type

Choose Standard Headrest Type

Headrest Options

Universal Hardware Adaptor (Adaptor only) ($57.00)

BACKREST CONFIGURATION & OPTIONS

Back Width Back Width

Back Height Back Height

Backrest Backrest

Back Options

Angle Adjustable Back (No Charge)

Recline Kit (WAMI) ($560.00)

Endomorph Canes (SEICF160L) (No Charge)Endomorph Canes (SEICF160L) (No Charge)

TRAY CONFIGURATION (ALL UPCHARGE)

Choose Tray (All ADP Approved)

ACCESSORIES

Choose Seat Belt (Upcharge)

Seat Belt (Auto Style) ($26.00)

Seat Belt (Padded) (SERND0030) ($56.00)

Seat Belt (4 Point Padded) (SERND0020) ($130.00)

Other Accessories

Transport Tie Downs Front ($85.00)

Transport Tie Downs Rear ($85.00)

Oxygen Tank Holder (WEPX) ($195.00)

Adjustable IV Pole ($130.00)

Lateral Bite out (SELND0015) ($180.00)

8" Adductor (SELND0005) ($164.00)

10" Adductor (SELND0005) ($164.00)

12" Adductor (SELND0005) ($164.00)

Start Over

Power Plus STP Wheelchair Orderform