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.comAdobe InDesign 15.0 (Macintosh) Adobe PDF Library 15.0