GT Order Form - Quickie-Wheelchairs.com

Mark For: Submitting for: o Quote o OrderDate:Dealer Acct #:Dealer:Dealer Contact:Dealer Address:Dealer City:Confirmation Email:Confirm Via:PO#:Ship To:Attention:ST:( ) Fax: ( )ZIP:Quickie GTNovember 2012EIR3Dealer Phone:Address:Address:ADDITIONAL SHIPPING INFORMATIONShip To City:ST:o Fax o Email Ship To Phone: ( ) Fax: ( )The HCPCS CODES provided are based on code verification through PDAC or our interpretation of the code definitions.The use of HCPCS CODES does not ensure coverage or payment. For coverage information, verify the appropriate payer's coverage policy.ZIP:aOption #HCPCS aDefinition Price Option # HCPCSDefinitionPrice1. FRAME STYLE & SETUPoooooooooo145WM13Frame Angle (see Figure 1)145FA175°145FA880°145FA2 85°Frame Inset Per Side (See Figure 2)145FF1 0" NC145FF2 1" (NA w/ 12" wide) NC145FF32" (NA w/ 12", 13", or 14" wide)NC145FS34145FS35145FS36ooK0005Base ModelGT (265 lbs)Frame InsetFootrest Width0Subtract 0 from Frame Width1" Subtract 2" from Frame Width2"Subtract 4" from Frame WidthFrame Style (See Figure 3)Classic FramePerformance FrameXTR Suspension Frame Onlyavailable in Performance Frame Set Up$1,625.00NCNCNCNCNC$895.00145SK1 Light Shock (up to 180 lbs.) NC145SK3 Heavy Shock (up to 265 lbs.) NCDepth Adjustable Backrest (Optional)See Figure 5 Depth Adjust Backrest extends the frame rear of the seat sling,select a factory setting. NA on 19" and 20" Seat Depths.ooo145DP02145DP03145DP040 Setting Backrest at standardposition, field adjustable to -1" or -2"-1 Setting Backrest -1" offset, fieldadjustable to flush or -2"-2 Setting Backrest -2" offset, fieldadjustable to flush or -1"$165.00$165.00$165.00Figure 1 Figure 2 Figure 3Classic Frame - Traditional GT seatsling to front frame bend angledimensions.Performance Frame - Seat Sling tofront frame bend angle is 1.5" shorterthan the classic position.Front of back cane post to front edge ofseat sling will remain the same for bothClassic and Performance.ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 1

1. FRAME STYLE & SETUP (CONT)Seat Width Seat DepthSee Figure 2. Measure from outside of seat tube to outside of opposite seattube. XTR and J3 Back NA w/ 12" and 13" widthso 145S3 o 12" NCo 145S4 o 13" NCo 145S5 o 14" NCo 145S6 o 15" NCo 145S7 o 16" NCo 145S8 o 17" NCo 145S9 o 18" NCo 145S10 o 19" NCo 145W11 oE2201 20" $450.00See Figure .1 Measures from front of back post to front edge of seat sling. Seat sling will be1" shorter than depth ordered, but actual seat depth will remain the same as ordered.145SD5 12" NC145SD6 13" NC145SD7 14" NC145SD8 15" NC145SD9 16" NC145SD10 17" NC145SD11 18" NC145SD12 19" NC145SD13 E2203 20" $475.002. FRONT SEAT HEIGHT SET UPFront Seat HeightSee Figures 4 and 5 o 145SH20 18.5" NCo 145SH14 16" NC o 145SH21 19" NCo 145SH15 16.5" NC o 145SH23 19.5" NCo 145SH16 17" NC o 145SH24 20" NCo 145SH17 17.5" NC o 145SH26 20.5" NCo 145SH18 18" NC o 145SH27 21" NCFigure 4Front to Rear Seat Height DifferencesoooooooooooooooFrame Depth Max Seat Sqeeze12"/13" 2.5"14"/15" 3.0"16"/17" 3.5"18"/19"4.0"20" 4.5"Caster Wheels145CW1 3" Micro NC145CW3 4" Low Profile Polyurethane NC145CW31 4" Micro Lighted $70.00145CW72 4" x 1" Aluminum Polyurethane $80.00145CW44 4" x 1.25" Semi Pneumatic $55.00145CW64 4" x 1.5" Aluminum Soft Roll $135.00145CW5 5" Low Profile Polyurethane NC145CW51 5" Micro Lighted $85.00145CW65" Soft Roll (Grey) NA w/ Frog Legs $85.00145CW65 5"x 1" Aluminum Polyurethane $100.00145CW7 5"x 1.5" Semi Pneumatic $85.00145CW66 5"x 1.5" Aluminum Soft Roll$145.00145CW34 6" Polyurethane NC145CW35 6"x 1.5" Semi Pneumatic $85.00145CW68 6"x 1.5" Aluminum Soft Roll $160.00Caster ForkSee Figures 5 and 6ooo145CF27145CF45145CF32Short ForkShort Wide Fork (w/ 1.25" or 1.5" caster)Tall Wide ForkNCNCNCCaster Fork Suspensionooo145CF53145CF54145CF55E1015E1015E1015Frog Legs 0 weight to 100 lbsFrog Legs 101 lbs weight to 190 lbsFrog Legs 191 lbs weight to 265 lbs$395.00$395.00$395.00Figure 5FrontForkSTFH Short/Single Short Wide Tall Wide Frog Legs3" 16"-20" 16"-20.5" 16.5"-21" 17.5"-21"4" 16"-20.5" 16.5"-21" 16.5"-21" 17.5"-21"5" 17",18",19",20",21" 17"-21" 17"-21" 18.5"-21"6" NA NA 18"-21" 19",20",21"Caster75° Frame Angle80° Frame Angle85° Frame AngleCasterSize3"4"5"6"3"4"5"6"3"4"5"6"ForkShort, Short W, Tall WSingle SidedFroglegsFigure 6InsetInsetInset0" 1" 2" 0" 1" 2" 0" 1" 2"NANANANANAShort, Short W, Tall WSingle SidedFroglegs NA 2"Short, Short W, Tall W NA NA NASingle Sided NA NA NAFroglegs NA NA NA .5"Tall Wide NA NA NA 2"Froglegs NA NA NA NA 1.5" NA .5"Short, Short W, Tall WSingle SidedFroglegsNANANANANAAll NC ForksSingle SidedFroglegs NA NA NAShort, Short W, Tall W NA NA NA 1"Single Sided NA NA NA 1"Froglegs NA NA NA 2"Wide NA 1" NA NA NA 1"Froglegs NA NA NA NA NA NA 2"All NC ForksSingle SidedFroglegsTubular/Flat Flared PlatformShort, Short W, Tall W NA .5"Single Sided NA .5"Froglegs NA NA NA .5"Short NA .5" NA NA 2" .5"Short Wide/Tall Wide NA 1" NA NA 2" .5"Single Sided NA 1" NA NA 2" .5"Froglegs NA 1.5" NA NA NA 1.5"Tall Wide NA 2" NA NA NA 2"Froglegs NA NA 1.5" NA NA NA NA NA 1.5"NANANA= Go = No Go # = "Soft" Go with limited seat angleMin seat angle listed in cellORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 2

3. FOOTPLATE OPTIONSFootrestHeel loop or leg strap not included, See Footplate Options Sectiono 145F228 o Aluminum Tubularo 145F229 o Aluminum Tubular LongNCo 145F230 o Aluminum Tubular w/ Flat CoverNCo 145F231Aluminum Tubular Long w/ Flat Cover nco 145F234 K0040 Aluminum Platform (Ang. Adj.) $95.00o 145F235 oK0040 Aluminum Platform Long (Ang. Adj.) $95.00High Mount Platform NA w/ 12",o 145F278 K0040 13" W with 1" or 2" Inset or 14" or 15" $95.00W with 2" insets.NA with Tubular Footrest145AD1145AD2145AD3ooooAdaptive Platform SpacerAdaptive Platform 2" SpacerAdaptive Platform 4" SpacerAdaptive Platform 6" Spacer$95.00$95.00$95.00Footrest Options145HL5 K0038 Leg Strap $35.00145DI01Removable Snap On CoverNA w/ Platform Footrests$60.00145DI02 Wear Pads NA w/ Platform Footrests $50.00145A179 K0108 Positioning Plates for Platform Footrest $50.00145A54 K0038 Extra Leg Strap $30.00Rear Seat Height14" & 14.5" only available with 20" rear wheel. NA with Amputee Axle Plate. See Availability Matrix13" & 13.5" only available with 20" or 22" rear wheel. NA with Amputee Axle Plate.oooo145RH11145RH12145RH13145RH14 o13"13.5"14"14.5"NCNCNCNCooooooo145RH15145RH16145RH17145RH18145RH19145RH26145RH20 o15"15.5"16"16.5"17"17.5"18"NCNCNCNCNCNCNCoooo145RH27145RH21145RH37145RH2218.5"19"19.5"20"NCNCNCNC4. REAR SEAT HEIGHT SET UPooooooE2211E2212Rear Wheel TirePneumatic145RT2E2211E2213Pneumatic w/ Airless Insert$80.00145RT3 E2218 Full PolyNC145RT6E2211E2212High-Pressure Clincher$95.00145RT27E2211E2212Knobby V- Trak$95.00145RT21E2211E2212Schwalbe Marathon Plus Evolution $125.00145RT22 E2218 Kik® Mako Black$95.00145RT12E2211E2212Mountain Tire $95.00Rear Tire & Wheel Matrix145RT1 NCRear Wheel SizeUltra Lightweight Wheels only available with aluminum anondized handrimContact Built 4 Me for Spinergy color optionsoooooooooooo145RW3145RW8145RW1145RW90145RW91145RW92145RW93145RW94145RW77145RW78145RW28145RW42 o20" Mag Wheel22" Mag Wheel24" Mag Wheel20" Lite Spoke Wheel22" Lite Spoke Wheel24" Lite Spoke Wheel25" Lite Spoke Wheel26" Lite Spoke Wheel22" Ultra Lightweight Spoke Wheel24" Ultra Lightweight Spoke Wheel22" Spinergy SPOX Black24" Spinergy SPOX BlackNCNCNC$200.00$200.00NCNC$80.00$250.00$250.00$695.00$695.00ooo145RW96145RW44145RW32 o25" Spinergy SPOX Black26" Spinergy SPOX Black22" Spinergy LX Black$695.00$695.00$895.00o 145RW88 o 24" Spinergy LX Black$895.00o 145RW99 o 25" Spinergy LX Black$895.00o 145RW40 o 26" Spinergy LX Black $895.00o 145RW50 24" Mountain $250.00WheelUltraMag Lite SpokeTireLightweightSpinergyPneumatic20,22,24 20,22,24,26 22,24,26Pneumatic w/ Airless Insert 20,22,24 20,22,2422,24Full Poly 20,22,24 20,22,24High-Pressure ClincherKnobby V Trak by KendaSchwalbe Marathon22,24,25,262424,25,2622,24 22,24,25,262424,25,26Kik® Mako Black24 24,2524,2522" = 489 mm 24" = 540 mm 25" = 559 26" = 590oooo145HR1Aluminum AnodizedNC145HR4Plastic Coated NA w/ 25" & 26"Lite Spoke Wheels$95.00145HR22 Natural Fit - Standard Grip $375.00145HR23 Natural Fit - Super Grip $395.00145HR30 Natural Fit LT - Standard Grip $375.00145HR31 Natural Fit LT - Super Grip $395.00145HR24Spinergy Flex Rim Only availableon Spinergy LX wheels 24" & 25"$525.00145HR8145HR7HandrimAluminum and Plastic are not available on all wheels in all sizes. Natural Fits are NA w/ 26".Handrim Selection not applicable with Xtender Power Assist8 Oblique Projections NA w/ Kik tires,only available with Mag or SpokeOmit HandrimNA w/ Ultra Lightweight Wheels$240.00NCORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 3

4. REAR SEAT HEIGHT SET UP (CONT)oXtender Power AssistRear seat height is 18.5" to 20" & 0 camber, NA w/ Amputee Axle, Padded Swing Arms.Front To Rear Seat Height Range 0 to 1" difference, 24" wheels only. Not available with XTRor standard rear suspension. Anti-Tips no charge with Xtender145XT1 oE0986 Xtender Power Assist w/ Pneumatic $6,595.00Rear Suspension RatingSelection not required for XTR Suspensionoo145SV04145SV05From 0 weight to 100 lbs (Yellow)From 101 lbs weight to 190 lbs (Red)145SV06From 191 lbs weight to 265 lbs (Blue)NCNCNCoooooooXtender Handrim Options145XH1 3x Torque Multiplier- Plastic Coated NC145XH2 o 1.5x Torque Multiplier- Stainless Steel NCXtender Wheel Options145XA2E2211E2212 SPARE 24" Spoke Pneu Alum NC145XA4E2211E2213SPARE 24" Spoke Pneu Plastic$90.00Xtender Accessory145XA1 o Xtender Spare Nimh Power Pack $1,395.00Axle145AX1 o Quick Release SteelNC145AX13Quad Quick ReleaseOnly available with Mag wheels$90.00Axle PlatesSelection not required for XTR SuspensionStandard Short (COG 1" to 4.5")o 145AL40Some limitations with STFHo 145AL43 o Standard Long (COG 1" to 4.5")NCoo145AL37145AL38E0959E1015Amputee (COG -1" to 2.5")Suspension (COG-.5 to +3)NA with XTR Suspension Frame$175.00$395.00o 145AL39 Xtender (COG 1")NCNCCamber0,3,6 available with std frame. 0,4,8 available with XTR frame145CI10°NCo 145CI23°NCo 145CI3 4°NCo 145CI4 6° NCo 145CI5 8° NCooooooooo145CC11 -1"145CC10 -.5"145CC12 0"145CC1 .5"145CC2 1"145CC3 1.5"145CC4 2"145CC5 2.5"145CC6 3"145CC7 3.5"145CC8 4"145CC9 4.5"Center of GravityMeasure from front of back post to center of rear axle. XTR Suspension Framewill be factory set at 1.5", Xtender 1"Figure 7NCNCNCNCNCNCNCNCNCNCNCNCRear Seat toFloor HeightShort Axle Plate- Wheel Size:20 22 24 24 (559) 2613 14 15 15.5 1613.5 14.5 15.5 16 16.515 16 17 17.5 1815.5 16.5 17.5 18 18.516 17 18 18.5 195. BACKRESToooooooooooBack TypeMilitary Service Patches145BT3Non-Folding BackrestNC Only available on tension adjustable upholstery and Jay 3 Back145BT82 o Folding Lock Down Angle AdjNC145VU1US Marines Patch$90.00o 145VU2US Army Patch$90.00Height Adjustable Backresto 145VU3US Navy Patch$90.00145B110 o 10" - 14" Back Height NC145VU4US Air Force Patch$90.00145B127 o 12" - 16" Back Height NC145VU12US Coast Guard$90.00145B111 o 14" - 18" Back HeightNC145VU5Purple Heart $90.00145B137 o 16" - 20" Back Height NC145VU8Purple Heart with Marines Patch $145.00o 145VU9Purple Heart with Army Patch$145.00Back Upholsteryo 145VU10Purple Heart with Navy Patch$145.00145BU1 o Standard UpholsteryNC145VU11Purple Heart with Air Force Patch $145.00145BU8 o Adjustable$175.00145VU13Purple Heart with Coast Guard$145.00145BU57Vented $200.00145BU14Omit Upholstery (Use w/ JAY Backs) -$15.00Push Handleso 145PH6Integral Push HandlesNCJAY J3 BackFold-Down Push Handles NA w/ 10-o 145PH5145JB01JAY J3 BackSee OF14" Back Height or Standard Upholstery.$100.00o 145PH2Omit Push HandlesNCORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 4

5. ARMRESTIncludes angle adjustable receiver hardware. NA w/ Xtender. Some limitationsmay exist w/ integral push handles, some RSHs and wheel sizeso 145AA18 oE0973 Padded Swing-Away - Standard $175.00ooArmrest - Padded Swing AwayArmrest - Height Adjustable145AA11 E0973 Single Post Ht. Adjust. Std (8.5"-13.5") $260.00145AA29 E0973 Single Post Ht. Adjust. Low (7"-11") $260.00Armpad - For Height AdjustableSuggest using classic model for tray tablesoo145AM23145AM21Desk Length (10") ClassicDesk Length (10") ContourNCNC145AM24 Full Length (14") ClassicNCo 145AM22 Full Length (14") Contour NC6. Key Options & AccessoriesNot all wheel locks available in all seat depths, wheel sizes and COG settings.XTR suspension only available w/ high mount pusho 145WL1 o High Mount PushNCo 145WL2 o High Mount PullNCoooo145WL27145WL30145WL10145WL12Ergo ScissorCompactOmit Wheel LockDo Not MountNC$125.00NCNCExtension HandleOnly available w/ High Mount Push or Pull Wheel Lockso 145EH7 oE0961Extension handles (Pair) $60.00Only available w/ high mount push or pull. NA w/ clincher, poly, Kik, or Schwalbe, or Xtendero 145GA1 oE0974Grade Aid$150.00ooooo145AT1145AT3145SL1145SL6145CU1E0971oWheel LockGrade AidAnti TipsAnti Tips (Pair) $135.00Omit Rear Anti TipNCSeat SlingStandard Seat SlingOmit Seat SlingNC-$15.00CushionK0669 2" Cushion $95.00JAY Cushions (Optional)To order any JAY cushions on-chair, please see the JAY price list.Cushion name or part number must be filled out with desired width and depthJAY Bundled Cushiono 145JC20 Cushion Name or Part #Price ListWidth:Depth:Side GuardsAll side guards NA w/ Height Adj. Arms. Some interferance my exist w/ paddedSA arms at lowest settings145SG33 K0108 Plastic - Standard$125.00145SG29 K0108 Plastic - Low$125.00o 145SG12 K0108Carbon FiberNA w/ push or pull wheel locks$450.00ooooooooPack Accessories145A1Quickie Backpack Black $55.00145A2Quickie Kids Backpack Black$50.00145A8 Seat Pouch Black $45.00145A500Gel Cover Hanger/Frame$105.00145A994 Gel Cover Swing Away Arm $105.00Positioning Belt145A142 E0978 Belt 1.5" Auto Buckle Universal w/clamps $70.00145A12 E0978 Belt 2" Aircraft Buckle $110.00145A13 E0978 Belt 2" Aircraft Buckle Padded $120.00Spoke GuardsK0065 Quickie Black Spoke Guard$115.00 145A23Quickie Clear Spoke Guard $115.00 145A302Miscellaneous145A32 E0950 Wheelchair Tray $250.00o 145IG6 Neoprene Impact Guards $85.00o 145A51 E2207Crutch Holder Only available withIntegral or Fold Down push handles$195.00o 145A85 Bolt-On Push Handles $115.00o 145A96 Presta Valve Adapter $5.00o 145A83Tool Kit $45.00ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 5

6. Key Options & Accessories (Cont)ooooooooooooooooooo145C2BlackFrame Color145C10 Black Opal NC145C38 o Blue Opal NC145C36 o Candy Blue NC145C14 o Candy Purple NC145C35 o Candy Red NC145C128 o Copper NC145C6 o Forest Green NC145C127 Fuchsia NC145C126 Glow NC145C116 Matte Black NC145C117 Matte Green NC145C4 Midnight Purple NC145C5 Pearl Pink NC145C103 Rootbeer NC145C114 Sparkle Silver NC145C113 Titanium Color Paint NC145C11 Toxic Green NC145C8 Yellow NCNC145EB06145EB05Green $135.00145EB04 Purple $135.00145EB03Anodized Color PackageCamber tubes are titanium grey except for the black option. Frog Legs blackonly. Black only w/ amputee, Xtender, suspension axle plates.145EB02 Black NCBlue $135.00Red $135.00145EB01 Ti Grey $135.00oooCustom Frame Color145C112 Desert Camouflage $295.00145C43Mossy Oak Camouflage $295.00145C42Stars & Stripes $295.00o145C108Zebra (Choose above base color) Stdwith White unless above base paint ischosen NA w/ Black$295.00ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 6