01795 477280 [email protected] ineedawheelchair.co.uk
Page 2
CLIENT DETAILS
Client Name / Ref: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . .
Contact Name: . . . . . . . . . . . . . . . . . . . . . . . . . Tel No: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Contact Email: . . . . . . . . . . . . . . . . . . . . . . . . . . Dept: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address for estimate / invoicing: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Client Measurements
Min & Max
Client Weight:
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
max 25 kg
A - Seat Width:
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
13 - 27 cm
B - Seat Depth:
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
13 - 30 cm
C - Backrest Height:
. . . . . . . . . . . . . . . . . . . . . .
13 - 27 cm
D - Seat to Head Height: . . . . . . . . . . . . . . . . . . . . . .
13 - 27 cm
E - Footplate Height:
. . . . . . . . . . . . . . . . . . . . . .
13 - 27 cm
F - Chest Width: . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13 - 27 cm
G - Axilla Height: . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13 - 27 cm
SPECIAL BUNDLE OFFERS
- All included parts shown in orange
Special Offer Bundle A Includes:
Seat unit, buggy base, upholstery, hip guides,
lateral supports, head laterals, dynamic
harness, pelvic belt, rain cover, seat canopy
and vehicle tie downs.
DISPAC-A
Special Offer Bundle B Includes:
Seat unit, buggy base, upholstery, hip guides,
lateral supports, head laterals, dynamic
harness, pelvic belt and vehicle tie downs.
DISPAC-B
Once you have selected your bundle, please choose required colour overleaf.
