Order form for Agilis: Modular Seating System For internal use only Invoice No.: For internal use only Order No.: Version: 26.01.2016 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 1993-07-12) 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
Service charges for McLean GmbH / Agilis - Modular Seating System E 10103 Assessment / Measurement (incl. service charges) E 10104 Follow-up assessment E 10400 (Hr) Price per hour on site E 10410 First fitting E 10401 (Hr) Price per hour mechanic E 10500 Trimming of the Alu Frame Extras (Net Price) E 11014 Provisional cover E 11050 Incontinence coating (complete) E 11055 Incontinence coating (seat only) E 11019 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, 20-30 cm seat width E 11500=1 Agilis lightweight custom contoured seating system, size 1, 30-38 cm seat width E 11500=2 Agilis lightweight custom contoured seating system, size 2, 38-46 cm seat width E 11500=3 Agilis lightweight custom contoured seating system, size 3, 42-50 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 12010 Special colour E 12011 Screw set E 12012 Trimband E 12013 Trimband, narrow Delivery Deliver for first fitting Deliver later Fitting through McLean E 12400=1 Strengthener bar E 12500 Prone alu frame E 12600 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 11016 Sleeves for Belt Extras E 17310 Swing-Aside Bracket incl. mounting left right E 17101 Swing Away Abduction Block, incl. hardware and cover pluggable E 17131 Abduction Block Bracket, swing away, mini, detachable, incl. mounting and cover E 17015 Cover for Abduction Block Headrest E 13100=1 Combi E 13300 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 13900 Individual Headrest E 13900=1 Individual (complex) E 13008 padded, size 1 E 13009 padded, size 2 2 Headrest Hardware E 13010 straight (incl. accessories) E 13011 offset (incl. accessories) E... Charge-No. E 13015 Headrest Cover
Chest and Pelvic Straps E 15300 Chest and Pelvic Straps strengthened 0 mini 1 small 2 medium 3 large 4 extra large E 15 310 Shoulder Retraction Pad L R R+L E 15 350 Dynamic Thoracic Belt 1 2 3 E 15304 Dynamic Thoracic H-Belt, strengthened, size 0 E 15304 Dynamic Thoracic H-Belt, strengthened, size 1 E 15304 Dynamic Thoracic H-Belt, strengthened, size 2 E 15304 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 15 301 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 14100 rounded E 14101 rounded, mini E 14200 flat E 14210 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 14250 narrow Gel Armrests (pair) E 22100 Gel Armrest Pad size 1 size 2 E 14015 Cover for Armrest E 22200 Gel Armrest Pad, narrow size 0 size 1 size 2 Armrest Hardware (pair) E 14010 Mounting Plate E 14011 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 14050 stainless steel, with coned joint, mini E 14060 stainless steel, T-Form, mini Pelvic Retraction Pads E 15610 Pelvic Retraction Pads size 0 mini (SB 12-20 cm) size 1 (SB 20-32 cm) size 0 (SB 16-24 cm) size 2 (SB 30-40 cm) size 3 (SB 36-46 cm) Pelvic Harnesses E 15500 Pelvic Harness Customised version to order = 1 small E 15501 Pelvic Harness, T-Model 3 = 1 small
Lap Belts E 15100 = 40 mm Lap Belt with metal-buckle E 15400 = 40 mm Lap Belt with plastic-buckle = 50 mm E 15410 = 25 mm = 40 mm Neoprene Lap Belt E 15411 = 25 mm = 40 mm Neoprene Lap Belt with bandalier E 15412 = 25 mm = 48 mm Neoprene Lap Belt with metal-buckle = 38 mm E 15420 = 25 mm = 40 mm Neoprene Lap Belt with 2 plastic buckles E 15421 = 25 mm = 40 mm Neoprene Lap Belt with 2 plastic buckles and bandalier E 15422 = 40 mm Neoprene Lap Belt with plastic buckles, bandalier and one side pull E 15440 = 25 mm = 40 mm 4-point Neoprene Lap Belt E 15441 = 25 mm = 40 mm 4-point Neoprene Lap Belt and bandalier Neoprene Ankle Straps E 41400 Neoprene Ankle Straps, strengthened = 1 small Footplates Footplates, aluminium E 41100 with straps 1= 17 x 6 cm E 41210 with straps 1= 20 x 7 cm E 41200 without straps 2= 19 x 7 cm 3= 22 x 8 cm 4= 24 x 9 cm E 41220 without straps 2= 26 x 9 cm 3= 30 x 12 cm Flexi Footshells E 41250 Flexi Footshells = 1 small E 41700 Wrist Straps E 41800 strengthened Neoprene Wrist Straps = 1 small Therapeutic Tray E 18100 Therapeutic Tray = 1 small, rounded E 18200 Makrolon = 1 small, straight, straight E 18010 Hardware for Therapeutic Tray (swing-away) E 18300 Makrolon, = 1 small E 18020 Hardware for Therapeutic Tray (rounded, swing-away) slip-on 4
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
Space for your notes 6