TR40R Silhouette Order Form, 3 11 V1.3
User Manual: TR40R
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PinDot Series Silhouette Order Form Rev. 3-1-11 Custom Seating For ease of ordering, contact Pindot Customer Service Toll Free at: 800-451-3553 Fax: 800-834-4153 Attn: ContourU, 899 Cleveland St. Elyria, OH 44036 For Skribbl'r Digitizing Systems: E-mail Order Form and Digitized File to: ElyriaCustomSeating@invacare.com Company Name: Contact Name: Date: E-mail Address: Phone Number: Cell Phone Number: Fax Number: Purchase Order #: Ship To Address: City/State/Zip: Account #: Client Reference: Sensor Serial Numbers: Back Location Pointer Value Seat Data Form #: Seat Sensor #: Back Sensor #: Strap Back Sensor Back Back Data Form #: Mobility Base Information / Cushion Dimensions Brand: Model: Frame Width: Inside Rail Width: in in Frame Depth: Inside Back Cane Width: in in Seat Tube Diameter in Back Tube Diameter: in Seat Cushion Width: in Back Cushion Width: in Is This Order Going "With Chair" (NEW Invacare Chair) * Is This Is This Order Order Going Going "On "On Chair" Chair" (NEW (NEW Invacare Invacare Chair) Chair) * * Seat to Back Angle: Seat to Back Gap: degrees inches * When ordering cushions "With Chair" / "On Chair" fax this order form and the order for the Invacare Chair to Pindot Customer Service at 1-800-834-4153 If Invacare quote is to be converted to order, please provide Invacare quote # If Freedom wheelchair order will be shipped to Invacare for install, please give order # HR01S* Small Headrest includes Adapter Plate $322.00 TR40L Tray Receptacle - Left $128.00 HR02S* Large Headrest includes Adapter Plate $322.00 TR40R Tray Receptacle - Right $128.00 HR03S* 2-Step Headrest includes Adapter Plate $322.00 SB05 HR04S* Curved Headrest includes Adapter Plate $322.00 SLK00** ContourU Pelvic Strap Straight Lateral (Right or Left) $110.00 HR15 Headrest Adapter Plate $38.00 SLK05** 1/2" Offset Lateral (Right or Left) $110.00 AR20 Desk Length Armrest (Pair) $225.00 SLK10** 1" Offset Lateral (Right or Left) $110.00 AR24 Full Length Armrest (Pair) $225.00 SLK15** 1.5" Offset Lateral (Right or Left) $110.00 LB07 Small Footrest (Pair) $210.00 SL10S Lateral Insert Replacement Set $250.00 LB08 Large Footrest (Pair) $210.00 PDSLM Mulit-Bar Swingaway Lateral - Medium (Pair) $260.00 LT06 Legrest Tops (Pair) $225.00 PDSLL Mulit-Bar Swingaway Lateral - Large (Pair) $260.00 * HR15 Required when using Contour U pan Comments and Special Instructions ** Laterals Fit the Silhouette KwikFit Shell Only $40.00 Seat Cushion Specifications inches (variable from 8" to 24") Cushion Width: $735.00 Seat cushion 21" or greater, additional cost applies - see SO80 on price list Cushion Length: inches (variable from 8" to 24") $65.00 Seat cushion 21" or greater, additional cost applies - SO80 Measured from the back of the digitizer to the place on the client's thigh where you want the cushion to end, plus and additional 1" Foam Type Soft Firm Extra Firm TFEP TFNP CM06T CM06 Mounting To Fit Existing Pan: Wx New CU Pan Width x Wood Mount with T-nuts Wood Mount without T-nuts D Depth $195.00 $195.00 $135.00 ****If selecting Wood Mount specify Cover Type**** Cover Type Cover Type Cover Type IDB/SM IDB/MD IDB/LR Other Draw String Cover Zippered Cover 2-Piece Velcro Cover ** Infinity Drop Base 14" - 16" wide Infinity Drop Base 17" - 19" wide Infinity Drop Base 20" - 22" wide $240.00 $240.00 $291.00 ** 2 -piece cover not available if undercut selected Removable Covers PLRTK Polartek LYCRA Lycra DARLEX Darlexx DT-2 Standard Dartex DT-2R Reversed Dartex L-05 Black Rubber Backed Lycra L-06 Grey Rubber Backed Lycra L-13 Light Blue Rubber Backed Lycra L-14 Red Rubber Backed Lycra L-15 Teal Rubber Backed Lycra L-18 Purple Rubber Backed Lycra L-19 Burgundy Rubber Baacked Lycra L-20 Blue Rubber Backed Lycra L-23 Green Rubber Backed Lycra L-24 Spacer Mesh Additional Removable Covers SO25 Additional Cover Fabric: SO40 Inner Cover (Recovery) When opting a 2 - tone fabric selection must be indicated as "A" for contact surface, "B" for non contact surface $190.00 $190.00 Unless otherwise specified Seat Cushion will have Flat Bottom and Hook and Loop Velcro Mount and 4" Curved Rear Mounting Hardware HWWMK78 Wood Mounting Kit - 7/8 inch $205.00 HWPMK01 Pan Mounting Kit - 1 inch $205.00 OCMK01 J & L Brackets - 1 inch (rail cut only) $175.00 HWPMK78 Pan Mounting Kit - 7/8 inch $205.00 OCMK78 J & L Brackets - 7/8 inch (rail cut only) $175.00 HWWMK01 Wood Mounting Kit - 1 inch $205.00 FDI-538 Econo-Eze (Seat & Back Hardware)* $637.00 * Not Recommended for Invacare Solara. Seat Cushion Modifications SO90 Leg Length Discrepancy Shorten Left Leg by Shorten Right Leg by $65.00 inches inches Longer Leg will be the indicated cushion length SO16 Growth Style Length= SO77 SO92 CM30G CM30 " + Growth " = Total Length "Depth " CM09 Soft Spot - Std Foam* CM09V Soft Spot - Visco Foam* $95.00 Qty: $150.00 Qty: $250.00 1 inch or 2 inch Depth: $65.00 VF05 Comments and Special Instructions $210.00 Qty: 1 inch or 2 inch Depth: $65.00 $65.00 Recess with Gel Insert* Recess Only* $65.00 $60.00 1 inch or 2 inch Depth: $65.00 SO70 Railcut to " Width x SO74 Railcut to Contour U Pan SO73 Railcut to Infinity Drop Base Undercut Solid Wood Insert (sling reduction) Visco Foam Overlay 1/2" $250.00 * Specify size & location in comment section Back Cushion Specifications Cushion Width: inches (Variable from 8" - 24") CM30 $735.00 Recess Only* Cushion Height: Qty: $95.00 1 inch or 2 inch Depth: Back cushion 21" or greater, additional cost applies - see SO80 on price list inches (Variable from 8" - 24") $65.00 CM09 Soft Spot - Std Foam* Qty: $150.00 1 inch or 2 inch Depth: Back cushion 21" or greater SO80 on price list CM09V Soft Spot - Visco Foam* Qty: Measurement taken from the grid on Back Shape Sensor prior to filling gap. If no Fill Gap indicated, this will be your overall cushion height Foam Type Soft Firm Extra Firm Mounting SKF30 KwikFit Mounting for Backs VF05 Visco Foam Overlay 1/2" $250.00 * Specify size & location in comment section Removable Covers PLRTK Polartek LYCRA Lycra DARLEX Darlexx DT-2 Standard Dartex DT-2R Reversed Dartex L-05 Black Rubber Backed Lycra KwikFit Includes: Shell, Angle Adjustable Interfacing Hardware, L-06 Grey Rubber Backed Lycra Attachment Points for Pindot Headrest, and a custom Sew Cover L-13 Light Blue Rubber Backed Lycra L-14 Red Rubber Backed Lycra L-15 Teal Rubber Backed Lycra KwickFit Mounting for Backs will fit between the wheelchair canes. L-18 Purple Rubber Backed Lycra Cushion and Shell will be made 2 1/2" smaller than the wheelchair L-19 Burgundy Rubber Baacked Lycra width indicated. Standard KwikFit Mounted Back will have a 2" curved top. L-20 L-23 Blue Rubber Backed Lycra Green Rubber Backed Lycra $195.00 L-24 Spacer Mesh $195.00 $135.00 Additional Removable Covers SO15 Additional Cover Fabric: SO40 Inner Cover (Recovery) Wheelchair Frame Width TFEP TFNP CM06T CM06 $400.00 $250.00 1 inch or 2 inch Depth: inches (Variable 12" to 24") To Fit Existing Pan: Wx New CU Pan Width x Wood Mount with T-nuts Wood Mount without T-nuts D Depth ****If selecting Wood Mount specify Cover Type**** Cover Type Draw String Cover Cover Type Zippered Cover Cover Type 2-Piece Velcro Cover ** SO62 Tarsys - 1st Generation SO63 Tarsys - 2nd Generation SO64 Formula - Contoura SO65 Formula - Conventional SO66 Personal Back Shell ELITE Matrix Elite Shell Other When opting a 2 - tone fabric selection must be indicated as "A" for contact surface, "B" for non -contact surface $190.00 $190.00 Back Cushion Modifications SO17 Fill Gap Sensor Grid + inches = Total Cushion Height $65.00 SO70 $65.00 SO74 $65.00 SO78 Railcut to: Width x Railcut to Contour U Pan Railcut to KwikFit $502.00 SO76 I-Cut provide measurements below: Depth $65.00 $65.00 $65.00 $65.00 $450.00 Call C/S ****Unless otherwise specified Back Cushion will have Flat Bottom, Inches Hook and Loop Velcro Mount and 4" Curved Top**** Bottom of Mounting Hardware Chest Width Cushion to HWPMK01 Pan Mounting Kit - 1 inch $205.00 HWPMK78 Pan Mounting Kit - 7/8 inch $205.00 HWWMK01 Wood Mounting Kit - 1 inch $205.00 HWWMK78 Wood Mounting Kit - 7/8 inch OCMK01 J & L Brackets - 1 inch (rail cut only) $205.00 OCMK78 J & L Brackets - 7/8 inch (rail cut only) $175.00 FDI-538 Econo-Eze (Seat & Back Hardware)* $637.00 FDI-596 Econo-Eze (Back Hardware Only) HWABK Adjustable Back Mounting Hardware $596.00 $260.00 $175.00 Inches Second Cut Inches Bottom of Cushion to First Cut Client's Right Client's Left Comments and Special Instructions * Not Recommended for Invacare Solara. Invacare Corporation One Invacare Way Elyria, OH 44035-4190 USA 800-333-6900 Form No. 06-023 v1.3
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