Prescription Form Order number Contact person Customer email Contact person email This Prescription Form is used when ordering a single wheelchair (with accessories) in a particular configuration. For more info on different configurations and accessories see the Prescriber Information (doc.nr. 96715-1) and each specific Info Sheet. User manuals and assembly instructions are also available at hdrehab.com. All wheelchairs include Wheel-, Seat-, and Back frames, Adjustable push bar, Drive wheels, Castors, Caregiver brakes, Seat plate, Tip protectors, and Transport mounts. 22” models also include User brakes and Fenders. Info Sheet 96914-1 Chassis HD Motion 22 Manual wheelchair Seat width (cm) Seat depth (cm) HD Motion 16 Transport model Seat width (cm) Seat depth (cm) Seat width is measured between side supports of armrests. Seat depth is measured with back cushion. Info Sheet 96904-1 Wheels, 96911-1 Seat height Drive wheels pneumatic Drive wheel position Checkboxes marked with bold lines are included in the standard configuration. HD Rehab AB , Tryffelslingan 4, 181 57 Lidingö, Sweden

Prescription Form 3. CAMBER, HAND RIMS, SPOKE PROTECTION (model 22) Drive wheel camber Hand rims Stainless steel Info Sheet 96904-1 Wheels Checkboxes marked with bold lines are included in the standard configuration. Info Sheet 96901-1 Centre Leg Rest, 96902-1 Separate Leg Rests Leg rest alternative 1: Centre Centre Leg Rest, angle adjustable, short Centre Leg Rest, angle adjustable, std Centre Leg Rest, angle adjustable, long One-piece Footrest, short One-piece Footrest, standard Holes for straps in footrest plate Leg rest alternative 2: Separate Mount - Separate Leg Rests, angle adj. Leg rest...

Prescription Form Info Sheet 96903-1 Armrests Height (cm) Armrest Standard, standard side support Armrest Standard, long side support Armrest Standard, wedge support 5° Armrest Low, standard side support Armrest Low, long side support Armrest Low, wedge support 5° Armrest Angle Adjustable, standard side support Armrest Angle Adjustable, wedge side support 5° Armrest height is measured from seat plate. Info Sheet 96905-1 Backrest System Height (cm) Flexi-back extra short (XK) Solid back long (L) Solid back short (K) Solid back extra short (XK) Backrest height is measured from seat plate to top...

Prescription Form Info Sheet 96905-1 Backrest System sw30 Long back sw30 sw34 X-short Long back back Back cushion with Wings Back cushion Flat Extra cover with Wings Extra cover Flat Info Sheet 96913-1 Seat Cushion sw30 Short Seat cushion standard Seat cushion incontinence protection Extra cover, seat cushion standard Extra cover, seat cushion incont. prot. 9. ALTERNATE CONFIGURATIONS Alternate configurations of HD Motion wheelchairs must be evaluated for risk. Evaluate if there is an increased risk of tipping and/or pinching for the particular user with the desired modification. If there is,...

Prescription Form Info Sheet 96906-1 Headrest Headrest, large, with side brackets Headrest, large, w/o side brackets Headrest, small, with side brackets Headrest, small, w/o side brackets Side support Info Sheet 96910-1 Thoracic Support Wide position Straight 80, Fixed Straight 80, Swing Form 60, Fixed Form 60, Swing Form 80, Fixed Form 80, Swing Adjustable 80, Swing Narrow position Thoracic support mount Info Sheet 96909-1 Pommels Knee divider Small Knee divider Large Pommel mount HD Rehab AB , Tryffelslingan 4, 181 57 Lidingö, Sweden

Prescription Form Info Sheet 96908-1 Tray Table sw30 Tray table Plastic Tray table Wood Support table Table mounts, pair 14. BELT & BELT MOUNTS, HARNESS MOUNTS Positioning belt, 2-point, XS Chest harness mounting kit Info Sheet 96912-1 Positioning belt, 96920-1 Harness mounts 15. SPOKE PROTECTION & WHEEL COVERS Info Sheet 96904-1 Wheels Spoke protection for HD Motion 22, pair Wheel covers for HD Motion 16, pair Info Sheet 96916-1 Canopy Back piece for canopy Canopy mount with locking HD Rehab AB , Tryffelslingan 4, 181 57 Lidingö, Sweden

Prescription Form Side pads 1cm, pair Info Sheet 96914-1 Chassis Armrest Std / Angle adjust. 17. BAG HOOKS Bag hooks (pair) Info Sheet 96915-1 Bag hooks 13610-5 Info Sheet 96918-1 IV pole 20. OXYGEN TANK HOLDER Oxygen tank holder 2 liter Info Sheet 96917-1 Oxygen tank holder 56925 HD Rehab AB , Tryffelslingan 4, 181 57 Lidingö, Sweden