Power Wheelchair Retail Prescription Form TDXSP2271118 Tel: 01656 776222 Fax: 01656 776220 Email: [email protected] Online Spares available at: www.invacare.co.uk Easy Order Form Delivery Address : Order Qty : Order Date : Ordering made easier, order your chair with just a few ticks. Standard Features • • • • • • • • • • • • • • • • • • Standard Seating Unit One Piece Seat Plate 430mm (adjustable by arms 440mm ‐ 480mm) Standard Foam Cushion 50mm thick Backrest frame, detachable, height 480mm Tension Adjustable Backrest, Black fabric Upholstery Standard T‐Armrests, detachable with Short armpad Headrest, height, depth and sideways adjustable Manual settable seat Tilt 0° ‐ 20° Manual settable Recliner 0° ‐ 30°, in 3.75° steps Standard 80° Hangers with fixed footplate LiNX Control REM216 Drive, Actuators and Lights with Standard bracket Selection of 10 Stunning Shroud and Rim Colours Centre (Driving Wheels) 355mm x 76mm (14" x 3") Black Tyres with Gel foam inserts (Solid) 8 km/h (5mph) 4 Pole Motors and 73.5 Ah Batteries 8A (200 ‐ 250V) Charger 4 Point tie down system Light system with indicators & LED Headlights Lap Belt with auto lock (flexible mount in side rails) * Configurations may vary from the image shown Spec 1 - Base Price: £5,843 Packages below include the above standard features with a variation to the list, any chargeable options are included in the revised price. Changes / additions to standard package • Modulite Seating Unit • Telescopic Seat Frame and Plate with Side Rails (Seat width 380mm - 530mm) • Matrx Flo-tech Cushion • Backposts 540mm (Tall) • Flex 3 adjustable backrest plates with Laguna backrest cushion Spec 2 - Base Price: £6,263 Or

Changes / additions to standard package • Modulite Seating Unit • Telescopic Seat Frame and Plate with Side Rails (Seat width 380mm - 530mm) • Matrx Flo-tech Cushion • Backposts 540mm (Tall) • Flex 3 adjustable backrest plates with Laguna backrest cushion • Electric Tilt (0°-30°) with CoG shift Changes / additions to standard package • Modulite Seating Unit • Telescopic Seat Frame and Plate with Side Rails (Seat width 380mm - 530mm) • Matrx Flo-tech Cushion • Backposts 540mm (Tall) • Seat Lifter with electrical Tilt (300mm, 30°) with CoG shift • Manual Centre Mounted Hanger with angle adjustable...

UPHOLSTERY TYPE (Select for M31 & M53) ARJ2151 Black fabric Black Dartex Black Spacer fabric LiNX REMOTE & BRACKETRY Remote REM216 Drive, Actuators & Lights DRIVE UNIT OPTIONS SHROUD COLOURS (ALL COLOURED PARTS ARE DETACHABLE AND CHANGEABLE PLASTIC SHROUDS) ARJ0228 SpaceStation Silver Island Blue Grape JellyBean (Purple) Monster Green Tangy Orange Lights Out Black - Matt Invacare® Blue SpaceStation Silver Island Blue Grape JellyBean (Purple) Monster Green Tangy Orange Lights Out Black - Matt Invacare® Blue Need an option that’s not included on this form? - Please enter option code from our standard...