Freedom Easy Order Form

Freedom Easy Order Form

Finished Dimensions

Standard cut is Bolteron with foam rolled over edge.

I C D H A B E G F Wheelchair Specifications Model: __________________________________ Width: __________________________________ Depth: __________________________________ Freedom Designs Upholstery Selections 1. Choose Contact / Non-Contact 2. Choose Upholstery

3. Choose Component Seat Base Back Base _{Headrest Pad Lateral Pads}

Hip & Knee Pads

Body Contact Surfaces

Primary Upholstery Option: Number: Choose:

Secondary Upholstery Option: Number: Choose:

Non-Contact Surfaces

Primary Upholstery Option: Number: Choose:

Secondary Upholstery Option: Number: Choose: Monogram Option When ordering choose either Monogram or Embroidery Name: Script Block Thread Color: Embroidery Option Design: Seating Specifications A Back Height: _______________________ B Lateral Height: _______________________ C Lateral Width: _______________________ D Hip Width (rear): _______________________ E Set Up Seat Depth: _______________________ F Hip Width (front): _______________________ G ”E” + 3” for Growth: _______________________ H Seat Width: _______________________ I Back Width: _______________________

Important Note: To ensure quote accuracy, seat and back

width, depth and height dimensions must be provided. Seats and backs over 18” in width, depth or height are subject to oversize charges.

Freedom Easy Order Form

Freedom Designs, Incorporated

2241 N Madera Road, Simi Valley, CA 93065 phone: 800-331-8551 fax: 888-582-1509 e: [email protected]

Quote

Order

Clear Form Email Form to Cus-_{tomer Service}

Buyer:

Co./Account:

Location:

Contact #:

P.O.#:

Marked For:

Fax:

Email:



*

Freedom Easy Order Form

Step 1. Choose Hardware for Planar / Flat Seat

Note: Price includes 1/2” wood, 1-1/2” 4# foam and choice of upholstery. EE1 EZ Lite 1 EZ Lite 1-EXT 101-1000 101-1000A 101-7000 101-7500 101-10000 101-10000-EXT

Two Knobs/Hinge (Transport Approved) Two EZ Lite/Hinge

Two EZ Lite/Hinge (Transport Approved) Seat Insert - No T-nuts, No Hardware Seat Insert - T-Nuts only, No Hardware J/L Quick Release (Transport Approved) Four Knobs (Transport Approved) Four EZ Lite

Four EZ Lite Extended (Transport Approved)

$ 750 $ 518 $ 518 $ 250 $ 275 $ 668 $ 850 $ 620 $ 700 Step 2. Choose Modifications to Planar / Flat Seat

MOD-1K Anti-Thrust Seat $ 221 MOD-1Y Contour Seat $ 342 C

Height of anti-thrust shelf is 1” C = 3rd of set up seat up depth (see page1)

Leg trough depth is 1” Height of anti-thrust is 1” C = Half of set up seat depth (see page1)

MOD-1CR Asymmetrical - Long Right $ 92 MOD-1CL Asymmetrical-Long Left $ 92 A B C D A _________ B _________ C _________ D _________ B C A D A _________ B _________ C _________ D _________ MOD-1G MOD-1I MOD-1L MOD-1O MOD-1P MOD-1DD MOD-1EE MOD-1FF MOD-1GG MOD-1ROHO Seat

Cushion Separate From Wood Incontinence Liner

Grid Seat Modification Notch For Back Posts Hook & Loop Strips Modular Contour Seat

Foam Full Width / Wood Between Rails Removable Incontinence Slip Cover Track Mount Hardware - Long Dual Tracks

Freedom Seat ROHO Insert (see pg. 6 to specify order)

$110 $ 32 $350 n/c $ 49/pr $454 $172 $214 $ 56/pr $803 Step 3. Choose Foam

1.5” Std 4# Foam Only OR Custom/Omit Standard (see chart below)

Base layer to be:_________________ Middle layer to be:_________________ Top layer to be:________________

Seat Foam Chart

3# Foam $ 47 per 1” Firm Sunmate $ 86 per 1” Pudgee $219 per 1” 4# Foam $ 47 per 1” X-Soft T-Foam $ 93 per 1” Waffle $282 per 1/2” 5# Foam $ 49 per 1” Soft T-Foam $ 93 per 1” Waffle (over 18x16) $567 per 1/2”

Soft Sunmate $ 86 per 1” Medium T-Foam $ 93 per 1” Free Float $355 per 1/2” Med. Sunmate $ 86 per 1” Firm T-Foam $ 93 per 1” Free Float (over 18x16) $708 per 1/2”

Easy

Form

-

Solid

Seat

Inserts

E2609

Freedom Easy Order Form

Step 1. Choose Hardware for Planar / Flat Seat

Note: Price includes 1/2” wood, 1” 4# foam and choice of upholstery.

Easy

Form

-

Solid

Back

Inserts

E2617

EE2 Easy Clamp2 Fast Clamp2 Rotate 2 102-1000A 102-7500 102-Easy Clamp 102-32000

Two Knobs/Hinge (Transport Approved) Two Easy Clamps/Hinge (Transport Approved) Two Fast Clamps (Transport Approved)

Two Rotate Clamps/Hinge (Transport Approved) Back Insert - T-Nuts only, No Hardware

Four Knobs (Transport Approved) Four Easy Clamps (Transport Approved) Four Rotate Clamps (Transport Approved)

$646 $549 $443 $462 $275 $762 $639 $462

Step 2. Choose Modifications to Planar / Flat Back MOD-2I Curved Wood $141

MOD-2IA Curved Foam $121

MOD-2H I-MOD $134 MOD-2J T-MOD $134 D B E C A A________ B________ C________ D________ E________ A________ B________ C________ D________ E________ MOD-2L Bi-angular $318 MOD-2DD Adjust. Lumbar $314

Split at_____________________ from bottom Start at______________________ from bottom MOD - 2K MOD - 2ROHO Back MOD - 2S MOD - 2S1 MOD - 2GG MOD - 2JJ Grid Back Freedom Back ROHO Insert (see pg.7 to specify order) Foam-In-Place Modification Soft Medium Foam-In-Place (chemicals only) Soft Medium Ergo Adjustable Track Mount Hardware - Long Dual Tracks $350 $803 $272 $254 $443 $ 61/pr Step 3. Choose Foam

1” Std 4# Foam Only OR Custom/Omit Standard (see chart below)

Base layer to be:_________________ Middle layer to be:_________________ Top layer to be:________________

Back Foam Chart

3# Foam $ 47 per 1” Firm Sunmate $110 per 1” Pudgee $237 per 1” 4# Foam $ 47 per 1” X-Soft T-Foam $119 per 1” Waffle $282 per 1/2” 5# Foam $ 65 per 1” Soft T-Foam $119 per 1” Waffle (over 18x16) $567 per 1/2”

Soft Sunmate $110 per 1” Medium T-Foam $119 per 1” Free Float $355 per 1/2” Med. Sunmate $110 per 1” Firm T-Foam $119 per 1” Free Float (over 18x16) $708 per 1/2”

Freedom Easy Order Form

Easy Form - Positioning Accessories

Medial Thigh - Abductor/Pommel

C A B D A________ B________ C________ D________ Standard Sizes Small 3L x 3H x 3-2 Taper Medium 4L x 3H x 3-2 Taper Large 5L x 4H x 4-2 Taper X-Large 6L x 5H x 5-3 Taper EE3B-2 Flip Down Abductor $466

Wedge Or Oval

MOD-3E Abductor Pad Only $179 MOD-3F Extension Bracket/Abductor $ 29 EE3M Anti-Thrust Pelvic Harness $259 S M L XL or Hip Width________ Hip Guides

EE4A/B Fixed - Flush/Offset $249/pair EE4C Quick Release Hip Guide $498/pair MOD-4A Contour for Anti-Thrust $ 95/pair MOD-4D Extension Bracket/ $ 44/ea

A B _{A = 4” high or _____”}

B = Set up seat depth or _____”

Flush 1” 2”

Mounted at: Hip or Knee Trunk Supports

EE5A/B Fixed - Flush/Offset $249/pair EE5E Lift & Swing Away $498/pair EE5I Tracks $ 55/pair EE5J Fixed Swing Away Summer Winter $422/pair EE5K Lever Swing Away $665/pair EE5P Lever Swing Away Summer Winter $559/pair EE5Q Swing Away Summer Winter $702/pair EE5W NEW Push Button S/A $498/pair

MOD-5F Protective Covering Over Hardware $ 54/pair

B A A _______ B _______ 4L x 3H 5L x 4H 6L x 5H Tracks 3” Single 5” Single 7” Single 9” Single 11” Single 9” Double 11” Double Trunk Supports

Std. (1” thick) OR Thin (.5” thick) Flat OR Curved Flush 1” 2” Headrest Hardware

7700 Vertical and Horizontal Adjustment - Fixed Removable 7702 Flip Down - Not Removable

7708 Rock and Roll Removable

7709 Rock and Roll Flip Down - Not Removable 7711 NEW Adjust-Eze Multi-Position Removable

7733 Adaptaplate - Universal Plate - Freedom Designs and Other Manufactures 77Platemate Universal Plate for all Headrests - Whitmyer, Otto Bock, Stealth

Headrest Pads

7755 Extension Pad W_______________ x H_______________

7753 3-Piece Hinged Small 4W x 4H Medium 4W x 5H Large 5W x 5H 7756 Chubbie Small 10W x 4H Medium 12W x 5H Large 13.5W x 4.5H 7757 Low Profile Small 8.5W x 3.5H Medium 9W x 4H Large 3W x 4H 7760 Skinny Small 8W x 4.5H Medium 10W x 4.5H Large 12W x 4.5H

Standard Sizes Small 3L x 3H x 3-2 Taper Medium 4L x 3H x 3-2 Taper Large 5L x 4H x 4-2 Taper X-Large 6L x 5H x 5-3 Taper $151 $296 $413 $422 $242 $ 66 $ 45 $144 $330 $197 $156 $197

Freedom Easy Order Form

EE9B-D High Top, Buckle, Dynamic XS S M L EE9F-D 3 Point High Tops XS S M L Ankle Circumference= (5 1/2”-8 1/2”) (7 1/2”-10 1/2”) (9 1/2”-12 1/2”) (11 1/2”-14 1/2”) Ankle Supports

EE9 Shoe Holders - Velcro S SM M ML L XL EE9C Shoe Holders - Buckle S SM M ML L XL EE9G Shoe Holders - Combo S SM M ML L XL Shoe Sizing= (5”) (5.75”) (6.5”) (7.25”) (8”) (10”)

MOD-9G Foot Plate Pads - Pair W______ x D______ Shoe Holders

Foot Boxes

08-10000 Leg Cradles $633 08-11000 Foot Box $541 Hanger Mount

Footplate/Footboard Mount

W—Fits between hangers D ___________________ H ___________________

Easy Form - Lower Extremity Supports

$117 $177 $174 $174 $174 $169

Freedom Easy Order Form

Cut Out Cells & Base 6.5 3 8 4 9.75 5 Valve Hose Location Corner & Cell

Height R O 11.5 6 W S 13.25 7 15 8 16.5 9 18.25 10 20 11 Select Seat Choice Standard Asymmetrical Left Asymmetrical Right Other 21.75 12

FRONT OF INSERT

INCHES ARE FROM BASE EDGE TO EDGE OF INSERT

1. Start diagram at cell 1A which represents front left of cushion from client’s seated position. 2. Specify “Cell Height” (1”, 2”. 3” or 4”) by placing a number in each cell box.

3. Specify request to “Delete Cells with Base Intact” by typing an “X” in those cell boxes. 4. Specify request to “Cut Out Cells & Base” by typing a “C” in those cell boxes.

5. Specify “Valve Hose Location Corner & Cell Height” by typing “V1”, V2”, V3” or “V4” in that corner box.

Note: For multiple valve or custom valve locations and custom air chamber divisions call Freedom Designs Customer Service for assistance at 800-331-8551

PLEASE ALLOW 3-4 WEEKS FOR DELIVERY

1”

2”

3”

X

C

V1

V2

V3

4”

V4

MOD-1ROHO SEAT Freedom Seat ROHO Insert

$803.00

Freedom Easy Order Form

Cut Out Cells & Base 6.5 3 8 4 9.75 5 Valve Hose Location Corner & Cell

Height R O 11.5 6 W S 13.25 7 15 8 16.5 9 18.25 10 20 11 Select Back Choice Standard “I” Back “T” Back 21.75 12

TOP OF INSERT

PLEASE ALLOW 3-4 WEEKS FOR DELIVERY

1”

2”

X

C

V1

V2

V3

3”

INCHES ARE FROM BASE EDGE TO EDGE OF INSERT

1. Start diagram at cell 1A which represents top right of back from client’s seated position. 2. Specify “Cell Height” (1”, 2”. or 3”) by placing a number in each cell box.

3. Specify request to “Deleted Cells with Base Intact” by typing an “X” in those cell boxes. 4. Specify request to “Cut Out Cells & Base” by typing a “C” in those cell boxes.

5. Specify “Valve Hose Location Corner & Cell Height” by typing “V1”, V2”, or “V3” in that corner box.

Note: For multiple valve or custom valve locations and custom air chamber divisions call Freedom Designs Customer Service for assistance at 800-331-8551

MOD-2ROHO BACK Freedom Back ROHO Insert $803.00