ki wheelchair trial equipment
TRANSCRIPT
FAX TO: 0800 275 365 EMAIL TO: [email protected]
Head Office 181A McLeod Road, Te Atatu, Auckland PO Box 12 1454, Henderson, Auckland, New Zealand Freephone: 0800 115 222 Freefax: 0800 275 365 Email: [email protected] Website: www.dme.co.nz
Ki Wheelchair Trial Equipment Order Form
FOLDING
Catalyst 4
Catalyst 5
Spark
Date: PO/APPL #:
Therapist Name: Clients Name:
Phone: Fax:
Physical Address:
Where chair is to be sent. If not Therapist, include name and phone number
SERIAL NUMBER: ______________________
COMMENTS: _________________________________________________________________________________________________________________
SPECIFICATIONS - Please indicate desired requirement, we will endeavour to provide as close to request as possible
DETAILS OF TRIAL EQUIPMENT REQUIRED
MEASUREMENTS Requested Trial Set
Seat Width
Seat Length
Seat to Footplate
Back Height
Seat to Floor (Front)
Seat to Floor (Back)
Hanger Angle
Tip Point
FIXED
Tsunami
Little Wave
Swing Away
Fixed Front
Aluminium
Titanium
Aluminium
Titanium
Requested Sent
Camber
Back Angle
Castors
Rear Wheel size
Tyres
Pushrims
Quick/Quad Axles
1. Goods on trial must be purchased or returned within 5 days (unless agreed otherwise) 2. Goods must be returned in good condition. Damaged goods will be the responsibility of the client and the cost of the repairs will be invoiced. 3. Return freight to DME is the clients responsibility unless otherwise arranged
Return Address for Equipment: Durable Medical Equipment Ltd 181a McLeod Road Te Atatu South, Auckland
(Phone 0800 115 222 to discuss anything about the trial if necessary)
Requested Sent
Upholstery Sling
Standard Back
Tension Adjustable Back
Skirt Guards Fabric
Skirt Guards Drop In
Impact Guards
Requested Sent
Spoke Guards
Anti-Tips
Brakes - Type
Push Handles
- Height Adjustable
Armrest – Tubular
- T Height Adjustable
BACKREST REQUIRED: JetStream Pro ADI VTrak ConfigureFit
CUSHION REQUIRED: Roho Model: _____________________ Size: ____________ High/Low: _______
DETAILS OF THERAPIST REQUESTING EQUIPMENT
Ki Mobility Chairs Options Catalyst 4 – Folding Frame
Easy to transport, easy to push, the Catalyst 4 is the lightest and most energy-efficient folder on the market that use offset axle plates that offer rear-seat height adjustability. Series (K4 code)
This simple axle plate design allows vertical axle adjustments in five positions. The axle plate can be reversed to the back of the chair to increase the stability.
Catalyst 5 – Folding Frame – Aluminum or Titanium
Your best choice in ultra-lightweight mobility, the Catalyst 5 is a high-performance folding wheelchair.
The Catalyst 5 makes the most of your effort. Its patented design and industry-leading use of heat treating combine to create an ultra-rigid frame with rolling resistance comparable to the rigid-style frames.
Constructed from 6061-T6 aircraft aluminium, or titanium the Catalyst 5 is the lightest rigid performing folder on the market.
The Catalyst 5 is easy to transport, takes less effort to push and offers users innovative options and accessories.
Tsunami
An incredibly lightweight, rigid, open-frame manual wheelchair.
As light as any aluminium or Titanium wheelchair in its class, the oversized tubing used in the Tsunami provides rigidity usually found in more expensive materials. This rigidity results in an incredibly responsive ride.
With five different front-frame bend options and four tapers, you have the ability to design exactly the frame you want.
With the unique Crescent CG and Tubular Component System, you can adjust your seat depth as needed. Additionally, you have more Center of Gravity positions than any other chair on the market.
The Aluminium is fabricated from 6061-T6 aerospace aluminium, the Tsunami AL weighs just 8.5kg as standard, with a transport weight of 5kg.
Lower your chair weight to as low as 6.7kg by using our Superlight wheel package and the lightweight backrest.
With the Titanium, everything you get with the Tsunami AL, but lighter and stiffer still!
Made of Ti3AL/2.5V, the Tsunami Ti is 180gms lighter and another 20% stiffer than the AL frame. The scratch-resistant, polished titanium frame takes wheelchair performance to a new level.
PAEDIATRIC CHAIRS
Tsunami Little Wave
The Tsunami Little Wave, an incredibly lightweight, rigid-frame wheelchair, combines the unmatched maneuverability of a high-performance manual wheelchair with easy growth and adjustability.
Spark
The Catalyst Spark is a unique pediatric wheelchair specifically designed to be used with virtually any clinically prescribed seating system
NAME:
SENT:
CHECKED:
RETURNED: