Order form for Agilis: Modular Seating System

Transcription

1 Order form for Agilis: Modular Seating System For internal use only Invoice No.: For internal use only Order No.: Version: Manufactured from modules the Agilis offers an excellent Seating System for the moderately affected client where a symmetrical seating position is achievable. It offers a range of adjustment and is particularly interesting where growth problems may be experienced. It may be used for the active user where mobility and freedom of movement is a priority. The Agilis is manufactured directly from a measurement chart which is supplied by the Technician. Delivery Address / Invoice Address Company: Date: Address: Contact Person: Tel.No.: approx. fitting or delivery date: Quote Cast 1. Fitting 2. Fitting Delivery Date signed Purchase Order According to the Medical Devices Directive (Council directive 93/42/EEC of 14 June 1993 concerning medical devices, OJ No L 169/1 of ) is intended to harmonise the laws relating to medical devices within the European Union, it is necessary to complete the following. Order approved yes no manufacture immediately yes no we require an offer/quote yes no to be delivered and/or fitted yes no by McLean GmbH Signature: Therapist / Contact Person Name / Position: Institute: Address: Town / Post Code: Please complete Prescribing Person / Doctor Name: Tel.: Commission First / Surname: Date of birth: Address: Town / Post Code: Tel. / Fax: Measurements taken: Town: Tel./Fax: NHS Private Other 1

2 Service charges for McLean GmbH / Agilis - Modular Seating System E Assessment / Measurement (incl. service charges) E Follow-up assessment E (Hr) Price per hour on site E First fitting E (Hr) Price per hour mechanic E Trimming of the Alu Frame Extras (Net Price) E Provisional cover E Incontinence coating (complete) E Incontinence coating (seat only) E Belt sleeve (pair) In accordance with the general terms and conditions we would like to order the following: E 11500=0 Agilis lightweight custom contoured seating system, size 0, cm seat width E 11500=1 Agilis lightweight custom contoured seating system, size 1, cm seat width E 11500=2 Agilis lightweight custom contoured seating system, size 2, cm seat width E 11500=3 Agilis lightweight custom contoured seating system, size 3, cm seat width incl. 3 mm strenghtened alu-frame E 12100=0 Alu Frame, size 0 E 12100=1 Alu Frame, size 1 E 12100=2 Alu Frame, size 2 E 12101=2 Alu Frame, size 2, Colour strengthened, 3 mm grey red blue silver black Aluminium Frames E Special colour E Screw set E Trimband E Trimband, narrow Delivery Deliver for first fitting Deliver later Fitting through McLean E 12400=1 Strengthener bar E Prone alu frame E Aluminium sheet/ measurements: Trimming of Alu Frame before first fitting after first fitting Cloth Art. No. See our materials/cloth catalogue Seating Cover E 11517=R Cover for complex formed back E 11517=S Cover for complex formed seat E Sleeves for Belt Extras E Swing-Aside Bracket incl. mounting left right E Swing Away Abduction Block, incl. hardware and cover pluggable E Abduction Block Bracket, swing away, mini, detachable, incl. mounting and cover E Cover for Abduction Block Headrest E 13100=1 Combi E Lateral, small E 13500=1 Vario, small E 13500=2 Vario, large Charge-No. Headrest(-hardware) E 13600=1 Standard, small E 13600=2 Standard, large E Individual Headrest E 13900=1 Individual (complex) E padded, size 1 E padded, size 2 2 Headrest Hardware E straight (incl. accessories) E offset (incl. accessories) E... Charge-No. E Headrest Cover

3 Chest and Pelvic Straps E Chest and Pelvic Straps strengthened 0 mini 1 small 2 medium 3 large 4 extra large E Shoulder Retraction Pad L R R+L E Dynamic Thoracic Belt E Dynamic Thoracic H-Belt, strengthened, size 0 E Dynamic Thoracic H-Belt, strengthened, size 1 E Dynamic Thoracic H-Belt, strengthened, size 2 E Dynamic Thoracic H-Belt, strengthened, size 3 R=1 small, with zip R=2 medium, with zip R=3 large, with zip R=4 extra large, with zip E W=2 medium, female RW=2 medium, female, with zip W=3 large, female RW=3 large, female, with zip Armrests (-hardware) Armrests (pair) E rounded E rounded, mini E flat E channel form E 14300R=1 Anatomic Armrest with integrated hand pad (small, RH) E 14300L=1 Anatomic Armrest with integrated hand pad (small, LH) E 14300R=2 Anatomic Armrest with integrated hand pad (large, RH) E 14300L=2 Anatomic Armrest with integrated hand pad (large, LH) E narrow Gel Armrests (pair) E Gel Armrest Pad size 1 size 2 E Cover for Armrest E Gel Armrest Pad, narrow size 0 size 1 size 2 Armrest Hardware (pair) E Mounting Plate E flat, incl. Clamp-Adjuster E 14020»T«Mounting (incl. Clamp-Adjuster) E 14030=200 angle adjustable, 200 mm E 14030=400 angle adjustable, 400 mm E 14040R swing away, with coned joint, right E 14040L swing away, with coned joint, left E stainless steel, with coned joint, mini E stainless steel, T-Form, mini Pelvic Retraction Pads E Pelvic Retraction Pads size 0 mini (SB cm) size 1 (SB cm) size 0 (SB cm) size 2 (SB cm) size 3 (SB cm) Pelvic Harnesses E Pelvic Harness Customised version to order = 1 small E Pelvic Harness, T-Model 3 = 1 small

4 Lap Belts E = 40 mm Lap Belt with metal-buckle E = 40 mm Lap Belt with plastic-buckle = 50 mm E = 25 mm = 40 mm Neoprene Lap Belt E = 25 mm = 40 mm Neoprene Lap Belt with bandalier E = 25 mm = 48 mm Neoprene Lap Belt with metal-buckle = 38 mm E = 25 mm = 40 mm Neoprene Lap Belt with 2 plastic buckles E = 25 mm = 40 mm Neoprene Lap Belt with 2 plastic buckles and bandalier E = 40 mm Neoprene Lap Belt with plastic buckles, bandalier and one side pull E = 25 mm = 40 mm 4-point Neoprene Lap Belt E = 25 mm = 40 mm 4-point Neoprene Lap Belt and bandalier Neoprene Ankle Straps E Neoprene Ankle Straps, strengthened = 1 small Footplates Footplates, aluminium E with straps 1= 17 x 6 cm E with straps 1= 20 x 7 cm E without straps 2= 19 x 7 cm 3= 22 x 8 cm 4= 24 x 9 cm E without straps 2= 26 x 9 cm 3= 30 x 12 cm Flexi Footshells E Flexi Footshells = 1 small E Wrist Straps E strengthened Neoprene Wrist Straps = 1 small Therapeutic Tray E Therapeutic Tray = 1 small, rounded E Makrolon = 1 small, straight, straight E Hardware for Therapeutic Tray (swing-away) E Makrolon, = 1 small E Hardware for Therapeutic Tray (rounded, swing-away) slip-on 4

5 Measurement Chart H L E B E G C I F A K actual reqd. actual reqd. actual reqd. A=Seat width F=Height seat-armpit K=Foot length B=Chest width G=Height seat-shoulder L=Depth of chest C=Seat depth H=Height seat-top of head Seat/back angle D=Shoulder width I=Lower leg length Knee angle E=Armrest height J=Width of system Chest circumference 5

6 Space for your notes 6