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SMARTDRIVE ORDER & REQUEST FOR QUOTE FORM
SDMX2-SOF Rev. E
Toll-Free: 800.736.0925 · Email: sales.smartdrive@permobil.com · Fax: 888.411.9027

REQUEST A QUOTE
(please complete entire form)
Provider Information
Provider:
Provider Account #: Provider Location (if applicable):
Order Contact Name:
ATP / Therapist:
Phone:
E-mail:

PLACE AN ORDER - P.O. #:

Shipping

Quote #:
(if you do not already have a quote, please complete entire form)

Ship to provider address on file

Ship to alternate address:

Alternate Ship To Recipient:

Street:

City: State: Country:

Zip Code:

VA Contract # V797P-3217M

Mobility Products (All prices are in US Dollars / USD)
SmartDrive MX2+ Power Assist System (HCPCS Code: E0986)
MSRP: $7131.00 (now includes standard SwitchControl buttons and your choice of PushTracker at no additional charge)

Client / Mark For:

Wheelchair Make:

Wheelchair Model:

Rear Wheel Size: 22" / 501 mm 25" / 559 mm

24" / 540 mm 26" / 590 mm

Is this an Existing wheelchair or a New one being ordered at the

same time as this SmartDrive?

Existing

New

Frame Type: Rigid (if the wheelchair is a Motion Composites
APEX, please provide the rear seat height):

Folding (MUST provide the chair / frame width):

Special Frame, One-Arm Drive, etc.
(please specify):
SwitchControl Button Options SwitchControl Buttons (two), MSRP: $220.00 (standard
option included at no charge)
SwitchControl Button (one) with Mono Jack option,
MSRP: $370.00 (upgrade option with additional $150.00 charge)

PushTracker Options
Included with Power Assist System at no charge (check one box if desired):
Updated! PushTracker E2,
MSRP: $225.00, available in Shadow black · set up in minutes · no phone/WiFi required · SmartDrive apps pre-installed · easy to read touchscreen · most advanced Bluetooth connection
Original PushTracker, MSRP: $200.00,
available in black with three band sizes provided: Small, Medium and Large
Extra Accessories / Parts (check box(es) if desired): Carrying Bag, MSRP: $78.00 USB Power Bank (2600 mAh), MSRP: $20.00 Roller Replacement Kit, MSRP: $205.00
Order Notes:
Figure shown is for illustration purposes only and actual product may vary.

Send completed form via fax: 888.411.9027 or email: sales.smartdrive@permobil.com