Quote

Therapist Email
Therapist Firstname
Therapist Surname
Therapist Company
Funding Agency Please select:
If Other:
Purchase Order No.:

Client Name
Address:
Age
Proposed address for
fabrication of equipment
Any additional information

Sizing:

sizing chart
1 1 1
2 2 2
3 3 3
4 4 4
5 5 5
6 6 6
7   7
 
Pelvis Tilt Flexible Fixed Posteriror Neutral Anterior
Obliquity Flexible Fixed Down left Neutral Down Right
Rotation Flexible Fixed Post left Neutral Post Right
 
Spine: Scoliosis
Yes No
Flexible Fixed Concave from
Left Right
Region:

Kyphosis
Yes No
Flexible Fixed  
Lordosis Flexible Fixed Increased Decreased Neutral
 

Please indicate any issues with the following:

Joint ROM
Head Control
Skin Integrity
 

Equipment Information

Proposed Wheelchair: Make / Model:
Width: Depth:
 

Required features to be quoted:

Base cushion      Back support  
If maintaining part of clients current seating please indicate what this is:
 
Solid base Yes
No
If yes - flat pan on seat rails Drop base       1"       2"
ABS Rigidiser Yes
No
 
Pommel Yes No If yes - swing down incorporated into cushion
  Therapist to supply
  Other:
Back Support Planar Contoured Foam
Laterals Fabricator
to supply     
Therapist
to supply

Type:
Incorporated into seat back Fixed Bracket:
Left
Right
Swing Away:
Left
Right
Headrest Yes
No    

Fabricator to supply

Therapist to supply
Type:
Covers Extra Cover
Armrests Any requirement for specific adaptation:
Legrests  Any requirement for specific adaptation:
Hip Strap Fabricator to supply      Therapist to supply
Shoulder Straps

Yes
No     

Fabricator to supply      Therapist to supply
Type:

 

Custom Tray ABS Polycarb Padded     

Important Notes

1. MAPPS will use as standard the following items in fabrication, if you wish to have alternatives please indicate this on this form.

  • ABS (custom shaped) fixed laterals
  • AEL swing away Laterials with custom pads
  • Headreast(custom) with AEL bracketry
  • Pommel (swing down) with AEL bracketing
  • Hip Strap Motion Concepts 2/4 point
  • Shoulder Straps (custom back pack) 50mm/25mm
  • Dartex covers with one extra base cove

2. Please ensure that all anticipated requirements are on this form to allow accurate quoting. MAPPS understands that at the time of fabrication alternatives to the quoted requirements may be required and if this incurs a further cost a new or extra quote will be provided.

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