Freedom Designs, Inc Easy Form Date:

Quote

Dealer/Acct. #:

E-mail Address

Buyer:

Fax Number

Ship to Address:

Order

Confirmation

Install Program

Phone Number:

Freedom Seating on Freedom Frame

Marked For: Purchase Order #

Freedom Seating on Other Manufacturer’s Manual Frame

Wheelchair Specifications:

*Let other manufacturer know that frame needs to be shipped to Freedom

Model: P.O. for Frame

Width:

Finished Dimensions

Depth:

Standard cut is wood with foam rolled over edge

Seating Specifications: A - Back Height (Top Of Shoulder)

B - Lateral Height C - Lateral Width (Chest Width)

D - Hip Width E - Set Up Seat Depth (Back to Knee –1”)

G - “E” + 3” for Growth H - Seat Width I - Back Width

Upholstery, Monograms, and Designs: Total system covered in one upholstery? YES

NO

Contact Surface Non-contact Surface Monogram Name

Script

OR

BLOCK Font

Thread Color

Design 2241 N. Madera Rd, Simi Valley, CA 93065 SOEO 22015

Phone: 800 331-8551

Fax: 888 582-1509

www.freedomdesigns.com Page 1

Freedom Designs, Inc Easy Form - Seat Step 1.

Choose Hardware for Planar / Flat Seat M/F: _____________________ Note: Price includes 1/2” wood, 1-1/2” 4# foam and choice of upholstery.

EE1 EE1-No Hardware EZ Lite 1 EZ Lite 1-EXT 101-1000 101-1000A 101-7000 101-7500 101-10000 101-10000-EXT

Step 2.

Two Knobs/Hinge (transport approved) Two Knobs/Hinge - No Hardware Two EZ Lite/Hinge Two EZ Lite/Hinge (transport approved) Seat Insert Seat Inserts w/T-Nuts J/L Quick Release (transport approved) Four Knobs (transport approved) Four EZ Lite Four EZ Lite Extended (transport approved)

Choose Modifications to Planar / Flat Seat

MOD-1K

Anti-Thrust Seat C

MOD-1Y

Add $210

 Height of anti-thrust shelf is 1”  C = 3rd of set up seat up depth (see page1)

MOD-1CR Asymmetrical - Long Right Add $ 88 A

B

Contour Seat C

Add $362

 Leg trough depth is 1”  Height of anti-thrust is 1”  C = Half of set up seat depth (see page1)

MOD-1CL Asymmetrical-Long Left Add $ 88

C A

A _________ B _________ C _________ D _________

B

C

D

Cushion Separate From Wood Incontinent Liner Grid Seat Modification Notch For Back Posts Hook & Loop Strips Modular Contour Seat Foam Full Width / Wood Between Removable Incontinent Slip Cover Track Mount Hardware - Long Dual Tracks Freedom Seat ROHO Insert (see pg. 8 to specify order)

MOD - 1G MOD - 1I MOD - 1L MOD - 1O MOD - 1P MOD - 1DD MOD - 1EE MOD - 1FF MOD - 1GG MOD - 1ROHO Seat

Step 3.

$646 $237 $471 $471 $172 $225 $602 $698 $471 $471

A _________ B _________ C _________ D _________ D

Add $105 Add $ 30 Add $333 n/c Add $ 47/pr Add $432 Add $164 Add $204 Add $ 53/pr Add $765

Choose Foam

1.5” Std 4# Foam Only

Custom/Omit Standard (see chart below)

OR

Base layer to be:

Middle layer to be:

Top layer to be:

Seat Foam Chart 3# Foam

$ 45per 1”

Firm Sunmate

$ 82per 1”

Pudgee

$209per 1”

4# Foam

$45per 1”

X-Soft T-Foam

$ 89per 1”

Waffle

$269per .5”

5# Foam

$ 47per 1”

Soft T-Foam

$ 89per 1”

Waffle (over 18x16)

$540per .5”

Soft Sunmate

$ 82per 1”

Medium T-Foam

$ 89per 1”

Free Float

$338per .5”

Med. Sunmate

$ 82per 1”

Firm T-Foam

$ 89per 1”

Free Float (over18x16)

$674per .5”

2241 N. Madera Rd, Simi Valley, CA 93065 SOEO 22015

Phone: 800 331-8551

Fax: 888 582-1509

www.freedomdesigns.com Page 2

Freedom Designs, Inc Easy Form - Back Step 1.

M/F: _____________________ Choose Hardware for Planar / Flat Back Note: Price includes 1/2” wood, 1” 4# foam and choice of upholstery.

EE2 EE2-No Hardware Easy Clamp2 Fast Clamp2 Rotate 2 102-7500 102-Easy Clamp 102-32000

Step 2.

$646 $238 $549 $443 $462 $762 $639 $462

Two Knobs/Hinge (transport approved) Two Knobs/Hinge - No Hardware Two Easy Clamps/Hinge (transport approved) Two Fast Clamps (transport approved) Two Rotate Clamps/Hinge (transport approved) Four Knobs (transport approved) Four Easy Clamps (transport approved) Four Rotate Clamps (transport approved)

Choose Modifications to Planar / Flat Back

MOD-2I MOD-2IA

Curved Wood Curved Foam

Add $134 Add $115

MOD-2H MOD-2J

I-Mod T-Mod

Add $128 Add $128

E C

A________ B________ C________ D________ E________

B D A

MOD-2L

Biangular

Split at MOD - 2K MOD - 2ROHO Back MOD - 2S MOD - 2S1 MOD - 2GG MOD - 2JJ

Step 3.

B________ C________ D________ E________

Add $303

MOD-2DD

from bottom

Start at

Adjust. Lumbar

Add $299

from bottom

Grid Back Freedom Back ROHO Insert (see pg.9 to specify order) Foam-In-Place Soft Medium Foam-In-Place (chemicals only) Soft Medium Ergo Adjustable Track Mount Hardware - Long Dual Tracks

Add $333 Add $765 Add $259 Add $242 Add $422 Add $ 58/pr

Choose Foam

1” Std 4# Foam Only

OR

Base layer to be:

Custom/Omit Standard (see chart below) Middle layer to be:

Top layer to be:

Back Foam Chart 3# Foam

$ 45per 1”

Firm Sunmate

$105per 1”

Pudgee

$226per 1”

4# Foam

$ 45per 1”

X-Soft T-Foam

$113per 1”

Waffle

$269per .5”

5# Foam

$ 62per 1”

Soft T-Foam

$113per 1”

Waffle (over 18x16)

$540per .5”

Soft Sunmate

$105per 1”

Medium T-Foam

$113per 1”

Free Float

$338per .5”

Med. Sunmate

$105per 1”

Firm T-Foam

$113per 1”

Free Float (over18x16)

$674per .5”

2241 N. Madera Rd, Simi Valley, CA 93065 SOEO 22015

Phone: 800 331-8551

Fax: 888 582-1509

www.freedomdesigns.com Page 3

Freedom Designs, Inc Easy Form - Accessories M/F: ________________________

Medial Thigh - Abductor/Pommel EE3B-2

Flip Down Abductor $444 Wedge Or Oval MOD-3E Abductor Pad Only $170 MOD-3F Extension Bracket/Abductor $ 28 EE3M Anti-Thrust Pelvic Harness $247 S M L XL or Hip Width____

C

A________ B________ C________ D________

A B

Standard Sizes Small 3L x 3H x 3-2 Taper Medium 4L x 3H x 3-2 Taper Large 5L x 4H x 4-2 Taper X-Large 6L x 5H x 5-3 Taper

D

Hip Guides Fixed - Flush/Offset Quick Release Hip Guide Contour for Anti-Thrust Extension Bracket/Add

EE4A/B EE4C MOD-4A MOD-4D

$237/pair $474/pair A $ 90/pair $ 42/ea

B

A = 4” high or _____” B = Set up seat depth or _____”

Flush

1”

Mounted at:

Hip

2” or

Knee

Trunk Supports Fixed - Flush/Offset Lift Swing Away Tracks Fixed Swing Away Summer Winter Lever Swing Away Summer Winter

EE5A/B EE5E EE5I EE5J EE5K EE5P EE5Q EE5W MOD-5F

Lever Swing Away

Swing Away Summer Winter NEW Push Button S/A Protective Covering Over Hardware

$237/pair $474/pair $ 52/pair $402/pair $633/pair $532/pair $669/pair $474/pair $ 54/pair

A _______ B _______

B

Tracks 3” 5” 7” 9” 11” 9” 11”

4L x 3H

A

5L x 4H 6L x 5H

Trunk Supports Std. (1” thick) OR Thin (.5” thick) Flat OR Curved

Flush

1”

Single Single Single Single Single Double Double

2”

Headrest Hardware 7700 7702 7708 7709 7711 7733 77Platemate

Vertical and Horizontal Adjustment - Fixed Removable Flip Down - Not Removable Rock and Roll Removable Rock and Roll Flip Down - Not Removable NEW Adjust-Eze Multi-Position Removable Adaptaplate - Universal Plate - Freedom Designs and Other Manufactures Universal Plate for all Headrests - Whitmyer, Otto Bock, Stealth

$144 $281 $393 $402 $230 $ 63 $ 43

Headrest Pads 7755 7753 7756 7757 7760

Extension Pad W_______________ Small 10W x 4H 3-Piece Hinged Small 8.5W x 3.5H Chubbie Small 4W x 4H Low Profile Small 8W x 4.5H Skinny

x H_______________ Medium 12W x 5H Large 13.5W x 4.5H Medium 9W x 4H Large 13W x 4H Medium 5W x 4H Large 5W x 5H Medium 10W x 4.5H Large 12W x 4.5H

$124 $314 $188 $149 $188

Belts SB-3331 SB-3332 SB-3334 SB-3362

Squeeze Release, 2 pt., Center Pull Metal Push Button, 2 pt., Center Pull EZ-Release, 2 pt., Center Pull EZ-Release, 4 pt., Center Pull

2241 N. Madera Rd, Simi Valley, CA 93065 SOEO 22015

XS XS XS XS

S S S S

Phone: 800 331-8551

M M M M

L L L L

Fax: 888 582-1509

XL XL XL XL

$ 68 $ 90 $ 90 $110

www.freedomdesigns.com Page 4

Freedom Designs, Inc Easy Form - Trays and Foot Boxes M/F:_________________________ Ankle Supports High Top, Buckle, Dynamic 3 Point High Tops

EE9B-D EE9F-D

Shoe Holders EE9 EE9C EE9G

(5 1/2 - 8 1/2”)

Ankle Circumference =

Shoe Holders - Velcro Shoe Holders - Buckle Shoe Holders - Combo

S S S (5”)

Shoe Holder Sizing =

MOD-9G

X-Small X-Small

Foot Plate Pads - Pair

(7 1/2 - 10 1/2”)

ML ML ML

(6.5”)

Large Large

(9 1/2 - 12 1/2”)

M M M

SM SM SM (5.75’)

Medium Medium

Small Small

(11 1/2 - 14 1/2”)

L L L (8”)

(7.25”)

$111 $169

XL XL XL

$166 $166 $166

(10”)

$161

W ______ x D______

Foot Boxes 08-10000

Leg Cradles

08-11000

$603

Foot Box

$515

Hanger Mount

Footplate/Footboard Mount W—Fits between hangers D ___________________ H ___________________ Tray

What is the width of the frame _____________________? 08-1000 08-2000 08-6000 08-8000 08-12000 08-13000 08-16000

Lexan Tray w/Velcro Lexan Tray w/Channel Brackets & Ribs Lexan Tray w/Adjustable Hardware & Ribs Lexan Tray No Hardware EZ-Lite Tray EZ-Lite Tray with Ribs 1/4” Lexan Tray w/Hook & Loop

$197 $273 $220 $159 $170 $183 $106

Tray Sizes Size

Description

X-Small

10” - 11” wide chair, Tray dimensions—21”wide x 18” deep,

body cut out— 10” w x 7” deep

Small

12” - 13” wide chair, Tray dimensions—21”wide x 18” deep,

body cut out— 12” w x 7” deep

Medium

14” - 15” wide chair, Tray dimensions—24”wide x 22” deep,

body cut out— 14” w x 9” deep

Large

16” - 17” wide chair, Tray dimensions—26”wide x 24” deep,

body cut out— 16” w x10” deep

X-large

18” - 19” wide chair, Tray dimensions—28”wide x 14” deep,

body cut out— 18” w x10” deep

A _________ B _________ C _________ D _________

2241 N. Madera Rd, Simi Valley, CA 93065 SOEO 22015

Phone: 800 331-8551

Fax: 888 582-1509

www.freedomdesigns.com Page 5

Freedom Designs, Inc Easy Form - Anterior Chest Supports M/F: _____________________

MOD-6A-1 Strap Riser

EE6R

$5/pr.

$16

EE6U

EE6S

$16

EE6X

$16

$16

Size XXSmall XSmall Small Medium Large

EE6V

XLarge

$16

Length of Pad Chest Support

XXS

XS

S

M

L

XL

EE6R

12"

15.5"

17.25"

18.75"

20.25"

21.5"

EE6S

12.5"

14.25"

15.5"

17"

18.25"

20"

EE6U

N/A

10"

11"

11.75"

12.5"

14.5"

EE6V

N/A

10"

14"

16.25"

20"

22"

EE6X

N/A

N/A

9.25"

11.25"

13.5"

N/A

2241 N. Madera Rd, Simi Valley, CA 93065 SOEO 22015

Phone: 800 331-8551

Fax: 888 582-1509

www.freedomdesigns.com Page 6

Freedom Select Anterior Trunk Supports Buyer:____________________________ Co./Account:_______________________ Location:__________________________ Contact #:_________________________ P.O.:_____________________________ Marked For:_______________________ Fax:______________________________ Email:____________________________

Freedom Designs, Incorporated 2241 N Madera Road, Simi Valley, CA 93065 phone: 800-331-8551 fax: 888-582-1509 e: [email protected] www.freedomdesigns.com

Quote Select Standard

Order

Select Narrow

Select Standard Zipper

Select Narrow Zipper

Freedom Select Anterior Trunk Support Order

Part Number

Freedom Select Support

Dimensions A

B

C

D

E

Price F

G

SFDI-6SNZ-S

Select Standard Small

7.5

4.5

3.25

6

11

SFDI-6SNZ-M

Select Standard Medium

9.5

6.5

4

6.5

14.75

7.25

SFDI-6SNZ-L

Select Standard Large

10.5

7.5

4.5

6.75

18

9

SFDI-6SNZ-XL

Select Standard

10.5

7.5

4.5

7.75

21.75

10

22

$ 14ϯ

SFDI-6NNZ-M

Select Narrow Medium

9.5

6.5

4

3

14.75

7.25

17

$ 13ϯ

SFDI-6NNZ-L

Select Narrow Large

10.5

7.5

4.5

3.5

18

8

SFDI-6NNZ-XL

Select Narrow Extra Large

10.5

7.5

4.5

4.25

21.75

10

SFDI-6SZ-S

Select Standard Zipper Small

7.5

4.5

3.25

6

11

SFDI-6SZ-M

Select Standard Zipper Medium

9.5

6.5

4

6.5

14.75

7.25

SFDI-6SZ-L

Select Standard Zipper Large

10.5

7.5

4.5

6.75

18

9

SFDI-6SZ-XL

Select Standard Zipper Extra Large

10.5

7.5

4.5

7.75

21.75

10

22

$ 14ϴ

SFDI-6NZ-M

Select Narrow Zipper Medium

9.5

6.5

4

3

14.75

7.25

17

$ 13ϴ

SFDI-6NZ-L

Select Narrow Zipper Large

10.5

7.5

4.5

3.5

18

8

SFDI-6NZ-XL

Select Narrow Zipper Extra Large

10.5

7.5

4.5

4.25

21.75

10

FSATS 112013

5.25 13.75 $ 13ϯ 17

$ 13ϯ

19.75 $ 14ϯ

19.75 $ 13ϴ 22

$ 14ϯ

5.25 13.75 $ 13ϴ 17

$ 13ϴ

19.75 $ 14ϯ

19.75 $ 14ϯ 22

$ 14ϴ Page 7

Freedom Designs, Inc Easy Form - ROHO Seat Insert PO#___________________________ Cell Size

MOD-1ROHO SEAT

M/F:______________________________ $7.00 $7.00

Freedom Seat ROHO Insert

Note: Retail pricing includes any combination of specif cation option.

1”

FRONT OF INSERT COLUMNS

2”

INCHES CELLS

3”

3

4.75

6.5

8

9.75

11.5

13.25

15

16.5

18.25

20

21.75

1

2

3

4

5

6

7

8

9

10

11

12

A

B

C

D

E

F

G

H

I

J

K

L

4” 3

Deleted Cells Base Intact

X Cut Out Cells & Base

4.75

2

6.5

3 8

C Valve Hose Location Corner & Cell Height

V1 V2 V3 V4 Select Seat Choice Standard

Asymmetrical Left

Asymmetrical Right

1

4

9.75

5

11.5

6

13.25

7

15

8

16.5

9

18.25

10

20

11

21.75

12

R O W S

INCHES ARE FROM BASE EDGE TO EDGE OF INSERT 1. Start diagram at cell 1A which represents front left of seat from client’s seated position. 2. Specify “Cell Height” (1”, 2”. 3” or 4”) by placing a number in each cell box. 3. Specify request to “Delete Cells with Base Intact” by typing an “X” in those cell boxes. 4. Specify request to “Cut Out Cells & Base” by typing a “C” in those cell boxes. 5. Specify “Valve Hose Location Corner & Cell Height” by typing “V1”, V2”, V3” or “V4” in that corner box. Note: For multiple valve or custom valve locations and custom air chamber divisions call

Other

2241 N. Madera Rd., Simi Valley, CA 93065 SOEO 22015

PLEASE ALLOW 3-4 WEEKS FOR DELIVERY Phone: 800 331-8551

Fax: 888 582-1509

www.freedomdesigns.com Page 8

Freedom Designs, Inc Easy Form - ROHO Back Insert PO#___________________________ MOD-2ROHO BACK

M/F:______________________________ $765.00 $7.00

Freedom Back ROHO Insert

Note: Retail pricing includes any combination of specif cation option.

Cell Size

TOP OF INSERT

1”

INCHES CELLS

2”

COLUMNS

3

4.75

6.5

8

9.75

11.5

13.25

15

16.5

18.25

20

21.75

1

2

3

4

5

6

7

8

9

10

11

12

A

B

C

D

E

F

G

H

I

J

K

L

3” Deleted Cells Base Intact

X

3

1

4.75

2

6.5

3

Cut Out Cells & Base

8

4

9.75

5

11.5

6

13.25

7

V1

15

8

V2

16.5

9

18.25

10

20

11

21.75

12

C Valve Hose Location Corner & Cell Height

V3 Select Back Choice Standard

“I” Back

“T” Back

R O W S

INCHES ARE FROM BASE EDGE TO EDGE OF INSERT 1. Start diagram at cell 1A which represents top right of back from client’s seated position. 2. Specify “Cell Height” (1”, 2”. or 3”) by placing a number in each cell box. 3. Specify request to “Deleted Cells with Base Intact” by typing an “X” in those cell boxes. 4. Specify request to “Cut Out Cells & Base” by typing a “C” in those cell boxes. 5. Specify “Valve Hose Location Corner & Cell Height” by typing “V1”, V2”, or “V3” in that corner box. Note: For multiple valve or custom valve locations and custom air chamber divisions call Freedom Designs Customer Service for assistance at 800-331-8551

PLEASE ALLOW 3-4 WEEKS FOR DELIVERY 2241 N. Madera Rd., Simi Valley, CA 93065 SOEO 22015

Phone: 800 331-8551

Fax: 888 582-1509

www.freedomdesigns.com Page 9