Quickie Recliner Order Form - Quickie-Wheelchairs.com

Quickie ReclinerEIQR, Effective November 2005Account No: ___________________________________________________________________________________Drop Ship/Ship To: ____________________________________________________Date: ________________________________________________________________________Name: _______________________________________________________________P.O. #: ________________________________________________________________________Address: _____________________________________________________________Buyer: _________________________________________________________________ City: _________________________________________________________State:______________________Marked For: _________________________________________________________________________Zip Code:_____________________________Phone Number:_________________________K0004QUICKIE RECLINERQuickie Recliner $1,877.00FRAMESCushion017CU1 2" Cushion $95.00017CU2 Omit Cushion NCFrame Color 017CU4 Omit Sling -$15.00017C2 Black NC017C10 Black Opal NC Back Height017C1 Blue NC 017B29 E0966 Std 24" w/10" Headrest Ext NC017C38 Blue Opal NC 017B28 Std 24" Omit Headrest Ext NC017C12 Blue Velvet NC Back Upholstery017C36 Candy Blue NC 017BU1 Standard (Padded) NC017C35 Candy Red NC 017BU20 Sling NC017C39 Candy Turquoise NC 017BU21 Back Upholstery Sling with Cushion $105.00017C6 Forest Green NC 017BU14 Omit Upholstery -$15.00017C4 Midnight Purple NCARMREST017C37 Orange NC Armrest017C5 Pearl Pink NC 017AA8 E0973 Height Adjustable Adult $230.00017C40 Razzleberry NC 017AM1 Desk Length Armpad (10") NC017C11 Toxic Green NC 017AM2 Full Length Armpad (14") NC017C8 Yellow NC 017AH5 E0973 Height Adjustable Kids $230.00Custom Color 017BD5 Desk Length Armpad (10") NC017C41 Berry Vibrations $210.00 017BD4 Full Length Armpad (14") NC017C20 Graphite $210.00 017BD1 Omit NC017C42 Stars and Stripes $210.00Frame Width017W5 14" NCFOOTNOTES:017W6 15" NC added rigidity.017W7 16" NC017W8 17" 1 NC017W9 18" 1 NC017W10 19" 1 NC1 17"- 20" widths will come with an additional stabilizer bar for2 Not available with 8" casters.3 Available only on long frame or extra long for 19"-20" deep.4 Not available with short extension tubes.5 Available with 17" - 20" frame widths and composite, angle017W11 E2201 20" 1 $300.00 adjustable or platform flip-up footplates only; 14" - 15" wide only.Frame Length6 Only available with composite and adult angle adjustable footplates.017FL1 Kids (12"-14") 2 NC017FL9 Regular (15"-16") NC017FL18 Long (17"-18") NC017FL25 X-Long (19"-20") Steel Reinforced NCSling Depth017SD5 12" NC017SD6 13" $75.00017SD7 14" $75.00017SD8 15" $75.00017SD9 16" NC017SD10 17" 3 $75.00017SD11 18" 3 $75.00017SD12 19" 3 $95.00017SD13 E2203 20" 3 $300.00ACCOUNT INFORMATION7 Not available with kids frame length.8 Not available with high-push wheel locks.9 Only available with aluminum and angle adjustable footplates.10 Only available with adult angle adjustable and kids angleadjustable footplates.SEATINGBACKRESTPROPER USE OF HCPCS CODES DOES NOT ENSURE COVERAGE OR PAYMENT. FOR COVERAGE INFORMATION , VERIFY THE APPROPRIATE PAYER’S COVERAGE POLICY.

Quickie Recliner, November 2005017CW5 5" Low-Profile Polyurethane NC017CW7 5" x 1.5" Semi-Pneumatic $85.00017CW33 6" Pneumatic $75.00017CW34 6" Polyurethane NC017CW35 6" x 1.5" Semi-Pneumatic $85.00017CW21 8" Pneumatic 11,12 $85.00017CW32 8" Polyurethane 11,12 NC017CW36 8" x 2" Pneumatic 11,12 $145.00017CW37 K0064 8" x 2" Pneumatic w/Airless Insert 11,12 $225.00Caster Options017CS55 3/4" Longer Fork Stem Bolt NC017CS9 1-1/2" Longer Fork Stem Bolt NCK0073 Caster Pin Locks 13 $80.00017CS4 Quick-Release Caster Stems 14 $160.00Omit Caster WheelsNCFOOTREST(Choose from Option 1 or 2)Option 1: Hanger Type (Mount with Extension Tube)Hanger017H1 60 o Swing-Away NC017H2 70 o Swing-Away NC017H3 70 o V Swing-Away 17 NC017H24 K0053 Articulating 2,18 $325.00017H14 K0195 Elevating 20 $255.00017H32 Omit Hanger -$15.00Extension Tube (Required with Option 1.)017E1 Short (See matrix on right) NC Axle017E2 Medium (See matrix on right) NC 017AX17 Threaded NC017E5 Long (See matrix on right) NC 017AX1 Quick-Release $95.00017E14 Regular ELR NC 017AX11 Quad Quick-Release $185.00017E15 Long ELR NC Anti-Tip017E16 K0037 High Mount 21 $55.00 017AO1 E0971 Front Anti-Tip $150.00Footplate 017AT1 Rear Anti-Tip NC017F1 Composite w/Heel Loops NC017F2 K0038 Foam w/Leg Strap $55.00 FOOTNOTES:017F5 Aluminum 1 NC017F3 K0040 23 Adult Angle Adj. w/Heel Loops $150.00017F48 K0038 Platform Flip Up w/Leg Strap 3 $155.00017F7 Omit Footplate & Extension Tubes -$15.00Footrest Options017HL4 Omit Heel Loop NC1 Only available with elevating hangers.2 Not available with short extension tubes.3 Only available with 60 o , 70 o , or 70 o V hangers.4 Only available with adult angle adjustable and kids angleadjustable footplates.017HL6 Omit Leg Strap NC or 90 o footboard footplates.Impact Guard6 Not available with 8" casters.017IG2 Impact Guard Neoprene 3 $85.00Option 2: Hanger Type (Direct Mount)HangerCASTERS017H7 70 o Swing-Away Front Mount 4 NC017H8 80 o Swing-Away Front Mount 5 NC017H6 90 o Swing-Away 5,6 NC017H23 E0990 90 o Elevating 4,6,7 $255.00Extensions (optional)017E23 2" $30.00017E24 4" 6 $30.00Footrest5 Only available with kids angle adjustable, adult angle adjustable7 Available only with 14"-16" frame width.8 Not available with heel loops.9 Not available with heel loops; single leg strap standard.10 Only available for use in bottom fork holes.11 Not available with kids frame length.12 Not available with 90 o hangers or 90 o elevating legrest.13 Not available with 8" x 2" casters.14 Not available with caster pin locks; not available with 3/4" or1-1/2" fork stem bolt; not available with 8" x 2" casters.15 Only available on 24" wheels.16 Not available with mag wheels.17 Available with 17" - 20" frame widths and composite, angle adjustable,017F4 K0040 24 Kids Angle Adjust. (w/Leg Strap) 8,22 $150.00 foam or platform flip-up footplates only; 14" - 15" wide only.017F3 K0040 23 Adult Angle Adj. w/Heel Loops $150.00017F62 K0038 90 o Footboard (w/Leg Strap) 3,7,9 $150.0018 Only available with composite and adult angle adjustable footplates.19 Not available with high-push wheel locks.20 Only available with aluminum and angle adjustable footplates.21 Only Available with 60 o , 70 o Hangers.22 Only available on 14-16" wide chairs.23 Should additionally be billed as E0951.24 Should additionally be billed as K0038.AXLE AND WHEEL

Quickie Recliner, November 2005Rear Wheel TypeHandrim017RW8 22" Mag NC 017HR1 Aluminum Anodized NC017RW9 22" Spoke $200.00 017HR4 Plastic Coated $85.00017RW1 24" Mag NC 017HR7 Omit Hand Rim -$20.00017RW2 24" Spoke NC017RR25 Omit Rear Wheel & Axle -$55.00(Intended size for set up _________)FOOTNOTES:Rear Wheel Tire1 Only available on 24" wheels.017RT1 Pneumatic NC2 Not available with 22" wheels.017RT2 K0064 Pneumatic Airless Insert $70.003 Not available with low profile polyurethane tires.017RT3 Full Polyurethane NC4 Not available with polyurethane or high-pressure clincher tires or017RT4 Low Polyurethane 1 NC kids length frames.017RT6 High Pressure Clincher 1 $95.005 Not available with high-push wheel locks.017RT8 Kevlar 1 $95.006 Not available with height adjustable armrests.Projections7 Not available with kids length frames.(Projections not available on plastic coated)017HR8 8 Oblique 3 $195.00017HR9 8 Vertical 3 $195.00017HR10 12 Oblique 3 $195.00017HR11 12 Vertical 3 $195.00Wheel Lock (All in reverse mount)017WL18 High Mount Push NC017WL17 High Mount Pull NC017WL10 Omit Wheel Lock NC017WL16 Right Push/Left Pull NC017WL15 Right Pull/Left Push NCExtension Handle017EH1 E0961 6" Pair $60.00017EH3 E0961 6" Left $30.00017EH2 E0961 6" Right $30.00Grade Aid017GA1 E0974 Grade Aid 7 $150.00ACCESSORIESBackpack017A1 Black Utility Backpack $55.00017A2 Black/Charcoal Kids $50.00Seat Pouch017A8 Black $45.00Extra Leg Strap017A54 K0038 Black $30.00Miscellaneous017A82 Caddy $45.00017A83 Tool Kit $25.00Positioning BeltE0978 1.5" Auto Buckle $60.00017A12 E0978 2" Aircraft Buckle $85.00017A13 E0978 2" Aircraft Buckle Padded $115.00Spoke Guard017A23 K0065 Black $90.00017A24 K0065 Clear $90.00Touch-Up Paint017A27 Frame $25.00017A28 Cross Brace $25.00Color: __________________________Wheelchair Tray TableE0950 Tray Table $200.00Side Guard017SG4 Plastic Kids 6 $120.00017SD3 Plastic Regular 6 $120.00