Transcript
PinDot Series ContourU Order Form Rev. 10/20/09 C u s to m S e a tin g
For ease of ordering, contact Pindot Customer Service Toll Free at: 800-451-3553 Fax: 800-834-4153
Send Cast / Splint and Order Form to Pindot Custom Seating Attn: ContourU, 899 Cleveland St. Elyria, OH 44036 For Skribbl'r Digitizing Systems: E-mail Order Form and Digitized File to:
[email protected]
Company Name: Contact Name: Ship To Address: City/State/Zip: Account #: Certification #: Client Name:
Date: Best Time to Contact: E-mail Address: Phone Number: Cell Phone Number: Fax Number: Purchase Order #:
Molding Bag Measurements Penny Location/ # of Pennies
Molding Bag:
Description
Modify To:
Mobility Base Information / Cushion Dimensions
A / (2)
Chest Width
N/A
Brand:
B / (2)
Waist Width
N/A
Frame Width:
in
Frame Depth:
in
C / (2)
Hip Width
N/A
Inside Rail Width:
in
Inside Back Cane Width:
in
D / (1)
Leg Length / Right
Seat Tube Diameter
in
Back Tube Diameter:
in
E / (1)
Leg Length / Left
Seat Cushion Width:
in
Back Cushion Width:
in
F / (1)
Back Height
G / (1)
Top of Lateral Height-Right
N/A
H / (1)
Top of Lateral Height-Left
N/A
Is This Order Going "With Chair" (Invacare Chair)
Seat-Back Angle, in Degrees = Center Lines:
(
Center Shapes
or
Is This Order Going "On Chair" (Invacare Chair) When ordering cushions "With Chair" or "On Chair" fax this order form and the order for the Invacare Chair to Pindot Customer Service at 1-800-834-4153
Leave as Marked
BOLD print selections are priced individually, Refer to Price List for details
Model:
)
Accessories HR01S Small Headrest includes Adapter Plate HR02S Large Headrest includes Adapter Plate HR03S 2-Step Headrest includes Adapter Plate HR04S Curved Headrest includes Adapter Plate HR15 Headrest Adapter Plate * * (doesn't work with Freedom t-nut pattern) AR20 Desk Length Armrest AR24 Full Length Armrest
LB07 Small Footrest LB08 Large Footrest LT06 Legrest Tops GL01 Regular links GL03 Extra Strong Links GL10 Dial Links - Required if Seat to Back Angle is > 105 TR40L Tray Receptacle - Left TR40R Tray Receptacle - Right SB05 ContourU Pelvic Strap 1034744 Chest Positioning Strap
Seat to Back Junctions Junction
Growth in Inches
Open to Rear
Inches of Gap
Style of Gap
Universal
Std.
Tongue
Full
Hip Control
Std.
Tongue
Full
Tongue
Full
Fixed Recline (>105)
N/A
Pelvic Control
N/A
Comments and Special Instructions
Yes
No N/A
Full Only
Seat Cushion Specifications
Standard Foam
Soft Foam
Covering Options Qty
CM01S Vinyl Upholstery (Non Removable) BKV Black Vinyl WWV Wedgewood Blue Vinyl SAV Sage Green Vinyl TAV Taupe Vinyl PGV Purple Gray Vinyl GMV Gunmetal Gray Vinyl
Qty
Additional Cloth Covers CM78S Additional Cover for Vinyl Cushion CM76S Additional Cover for Naked Cushion Fabric: SO40 Inner Moisture Resistant Cover
Qty
Mounting TFNP New Pan If Leg Length Discrepancy, Size Pan to fit: Short Leg or Long Leg TFEP To Fit Existing Pan: Seat Width: Seat Length: inches CM31V Upholstered Bottom with Velcro CM31 Upholstered Bottom without Velcro CM03 Untrimmed CM06 Wood Mount without T-Nuts CM06T Wood Mount with T-Nuts Specify Non-Std T-Nut Pattern: * Wood Stiffeners are Std on Cushions Without a Wood Mount
CM02S Naked (Removable Cloth Cover Included) CMP Polartek CMS Lycra CMD Darlexx * (moisture resistant material) DT-2 Standard Dartex * (moisture resistant material) DT-2R Reversed Dartex * (moisture resistant material) L-05 Black Rubber Backed Lycra L-06 Gray Rubber Backed Lycra L-13 Light Blue Rubber Backed Lycra L-14 Red Rubber Backed Lycra L-15 Teal Rubber Backed Lycra L-18 Purple Rubber Backed Lycra L-19 Burgundy Rubber Backed Lycra L-20 Blue Rubber Backed Lycra L-23 Green Rubber Backed Lycra L-24 Tytex Spacer Fabric Cover Style Draw String (Std) 2 Piece w/Velcro
Mounting Hardware HWPMK01 Pan Mounting Kit - 1 inch HWPMK78 Pan Mounting Kit - 7/8 inch HWWMK01 Wood Mounting Kit - 1 inch HWWMK78 Wood Mounting Kit - 7/8 inch OCMK01 J & L Brackets - 1 inch (rail cut only) OCMK78 J & L Brackets - 7/8 inch (rail cut only) FDI-538 Econo-Eze (includes Seat & Back Hardware)
Seat Modifications Adductor - Right CM46 As Molded CM47 Raised CM36 Extended Adductor - Left CM46 As Molded CM47 Raised CM36 Extended Adductor Reinforcement CM48 Standard Reinforced CM50 L - Shaped Reinforced CM80 Aluminum Reinforced Abductor CM54 As Molded CM37 Raised CM34 Extended CM23 Front Rigging Notches Width: Length: Depth:
CM22 CM38 CM13 CM13 CM40
inches inches
inches inches
Rail Cut Finished Rail Cut Width = Loose Fit (1/4" Increments) Undercut - Right Undercut - Left Diagonal Cut
Show Placement on Cast/Image for These Modifications CM12 Pelvic Strap Notches, 2" Standard CM33 Cross-Brace Notches, Refer to Tech Notes CM17 Notched Rear Corners, 1" x 2" Standard CM20 Strap Slots, 1/2" x 1 1/2" Standard - Naked Only CM30G Recess with Gel Pad Insert CM30 Recess Only Qty: 1 or 2 inch Depth: CM09 Sofspot - Std Foam Qty: 1 or 2 inch Depth: CM09V Sofspot - Visco Foam Qty: 1 or 2 inch Depth: CM09P Duplicate Sofspot Pad (Vinyl Only)
inches inches
inches
VF05 VF01 SF05 SF01
Comments and Special Instructions
Visco Foam Overlay 1/2" Visco Foam Overlay 1" Standard Sofspot Foam Overlay 1/2" Standard Sofspot Foam Overlay 1"
For Office use Only Intake Calib. Set-Up Pull Audit
Serial No.
# of Cushions
Width
RailCut
Length
Longer/Shorter
inches inches inches inches inches
Cast
/
Digital File
Returned Cushions Name:
After Roll
Splint
Overlays only available on Naked Cushion
Back Cushion Specifications
Standard Foam
Soft Foam
Covering Options Qty
CM01B Vinyl Upholstery (Non Removable) BKV Black Vinyl WWV Wedgewood Blue Vinyl SAV Sage Green Vinyl TAV Taupe Vinyl PGV Purple Gray Vinyl GMV Gunmetal Gray Vinyl
Qty
Additional Cloth Covers CM78B Additional Cover for Vinyl Cushion CM76B Additional Cover for Naked Cushion Fabric: SO40 Inner Moisture Resistant Cover Cover Style Draw String (Std) 2 Piece w/Velcro
Qty
Mounting
CM02B Naked (Removable Cloth Cover Included) CMP Polartek CMS Lycra CMD Darlexx * (moisture resistant material) DT-2 Standard Dartex * (moisture resistant material) DT-2R Reversed Dartex * (moisture resistant material) L-05 Black Rubber Backed Lycra L-06 Gray Rubber Backed Lycra L-13 Light Blue Rubber Backed Lycra L-14 Red Rubber Backed Lycra L-15 Teal Rubber Backed Lycra L-18 Purple Rubber Backed Lycra L-19 Burgundy Rubber Backed Lycra L-20 Blue Rubber Backed Lycra L-23 Green Rubber Backed Lycra L-24 Tytex Spacer Fabric
Mounting Hardware
TFNP New Pan TFEP To Fit Existing Pan: Back Width: Back Height: inches CM31V Upholstered Bottom with Velcro CM31 Upholstered Bottom without Velcro TFCS-Fit to Custom Shell: CM03 Untrimmed CM06 Wood Mount without T-Nuts CM06T Wood Mount with T-Nuts Specify Non-Std T-Nut Pattern: * Wood Stiffeners are Std on All Cushions Without a Wood Mount
HWABK Adjustable Back Mounting Hardware HWPMK01 Pan Mounting Kit - 1 inch HWPMK78 Pan Mounting Kit - 7/8 inch HWWMK01 Wood Mounting Kit - 1 inch HWWMK78 Wood Mounting Kit - 7/8 inch OCMK01 J & L Brackets - 1 inch (rail cut only) OCMK78 J & L Brackets - 7/8 inch (rail cut only) FDI-538 Econo-Eze (includes Seat & Back Hardware) FDI-596 Econo-Eze (Back Hardware Only)
Back Modifications Lateral - Right CM49 As Molded CM51 Square Pull inches CM52 Extend Existing Shape inches Lateral - Left CM49 As Molded CM51 Square Pull inches CM52 Extend Existing Shape inches Lateral Reinforcement CM16 Standard Reinforced CM39 L - Shaped Reinforced CM21 Aluminum Reinforced CM534R Swing Away Lateral Right (Naked Only) CM534L Swing Away Lateral Left (Naked Only) ** Swing Away Laterals must be accompanied by CM21
VF05 VF01 SF05 SF01
Visco Foam Overlay 1/2" Visco Foam Overlay 1" Standard Sofspot Foam Overlay 1/2" Standard Sofspot Foam Overlay 1"
CM22 CM38 CM13 CM40
Rail Cut Finished Rail Cut Width = Loose Fit (1/4" Increments) Undercut Diagonal Cut
inches inches inches inches
Show Placement on Cast/Image for These Modifications CM20 Strap Slots 1/2" x 1 1/2" Standard Strap Slots Available on Naked Only and Cannot Intersect a Sofspot CM30G Recess with Gel Pad Insert CM30 Recess Only Qty: 1 or 2 inch Depth: CM09 Sofspot - Std Foam Qty: 1 or 2 inch Depth: CM09V Sofspot - Visco Foam Qty: 1 or 2 inch Depth: CM09P Duplicate Sofspot Pad (Vinyl Only) Overlays only available on Naked Cushion
Comments and Special Instructions
For Office use Only Intake Calib. Set-Up Pull Audit
Serial No.
# of Cushions
Width
Rail Cut
Length
Tongue
Cast
/
Digital File
Returned Cushions
Splint
Name: After Roll Form # 00-285
