Fillable Chairman Koala Mini-Flex (Accident Compensation Corporation New Zealand)

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Chairman Koala Mini-Flex (Accident Compensation Corporation New Zealand)

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PO#:
_____________________________
_
* Shipping Location:_____________________________
_
Address:
_____________________________
_
* Phone#:_____________________________
_
* Contact:_____________________________
_
* City:_____________________________
_
* Fax#:_____________________________
_
* Weight:______________________________
_
*Height:______________________________
_
A) Top of Shoulders:
______________________________
B) Chest Depth:
______________________________
C) Chest Width:
______________________________
D) Seat Depth:
______________________________
E) Top of Head:
______________________________
F) Elbow to Hand:
______________________________
G) Seat Pan to Elbow:
______________________________
H) Hip Width:
______________________________
*I) Knee to Foot:______________________________
_
Permobil New Zealand Ltd
181A McLeod Rd, Te Atatu South
Auckland 0610, New Zealand
0800 115 222
permobil.com/en-nz
* State
:
_____________________________
_
Diagnosis:
_____________________________
_
Permobil recommends that the client is evaluated by a
certified rehab specialist.
Dealer Information
Client Information
Client Measurements
Funding Source:
_____________________________
_
Prices effective: September 1, 2020
Client Age:
_____________________________
_
Company Code:______________________________
* First Name:_____________________________
_
* Indicates a Required Field
* Last Name:_____________________________
_
Email Address:
_____________________________
_
Chairman Koala Mini-Flex
PERMNZ
Chairman Koala Mini-Flex
Chair Model and Colors
I106680-99-0
Koala Mini-Flex w/ R-net
Price Includes: FWD Koala Base Set Up For One Power Seat Function, R-net Electronics, Tie-
Down Hardware for Strap Systems, Charger and Standard Positioning Belt. Must Choose Flat
Free or Pneumatic Tires Below. Max Speed = 6.5 kmh, Weight Capacity = 35 kg, STFH =
375mm.
CHOOSE DRIVE TIRES:
DescriptionPart Numbe
r
Tri Spoke Split Rim w/ FF Drive Tires - 2.5 x 8"I103889-99-0
No Charge
Tri Spoke Split Rim w/ Pneumatic Tire - 2.5 x 8"I103890-99-0
No Charge
CHOOSE SHROUD COLOR
:
DescriptionPart Numbe
r
Shroud for Koala - Onyx BlackI105756-99-0
No Charge
Shroud for Koala - Pop Star PinkI105757-99-0
No Charge
Shroud for Koala - Platinum SilverI105758-99-0
No Charge
Shroud for Koala - Volcano RedI106369-99-0
No Charge
Shroud for Koala - Cobalt BlueI106370-99-0
No Charge
Shroud for Koala - Purple RainI106371-99-0
No Charge
Shroud for Koala - Extreme YellowI106372-99-0
No Charge
Shroud for Koala - Green AppleI106945-99-0
No Charge
CHOOSE HUBCAP COLOR:
DescriptionPart Numbe
r
Match Hubcap Color to Shroud: _____
Note: Hub caps will be matched to shroud color if no selection is made.
Solid Color Hub Cap - PairI10871
No Charge
Platinum Silver: _____ Onyx Black: _____ Cobalt Blue: _____ Phantom Gray: _____
Pop Star Pink: _____ Volcano Red: _____ Purple Rain: _____ Titan Blue: _____
Sublime Green: _____ Crystal Blue: _____ Vintage Wine: _____ Extreme Yellow: _____
Chili Pepper Red: _____
Base Options
MUST CHOOSE BATTERIES:
DescriptionPart Numbe
r
Batteries, Koala (40AH) Sealed Gel, x2, InstalledI101979-99-0
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Light Kit - Koala I106860-99-0
Front Bumper KoalaI100865-99-0
Enhanced Steering Perform Unit (ESP), R-netI106919-99-0
Recommended item with switched drive inputs for improved tracking.
Programming Key for R-net - Permobil VersionID51113
Joystick Options
PLEASE NOTE:
For additional input devices, refer to Alterative Drive Systems section.
Permobil Joystick Module I108319-99-0
Designed exclusively for Permobil, this R-net color joystick features: control of up to 4
Bluetooth devices, Infrared control, programmable buttons and a programmable switch jack; al
l
in a compact, durable Aluminum housing.
Page 2 of 10
Rev 2020-1 08/17/2020
Chairman Koala Mini-Flex
Joystick Options
R-net LED Remote Joystick - No DisplayI105246-99-0
No Charge
This Joystick does NOT have a Display Screen, does NOT contain mono jack ports, and does
NOT include Bluetooth or Assignable Buttons. PC Programming required and profiles limited t
o
five.
CHOOSE JOYSTICK HANDLE TYPE:
DescriptionPart Numbe
r
Cone Shaped Joystick Knob - StandardI10045
No Charge
Chin Cup For Joystick KnobI100960-99-0
"T" Handle For Joystick KnobI100961-99-0
"Large Ball" For Joystick KnobI100962-99-0
"Softball" For Joystick KnobI100963-99-0
"Mushroom" For Joystick KnobI100964-99-0
"Stick" For Joystick KnobI100965-99-0
1.75" Black Foam Ball For Joystick KnobI105442-99-0
Bodypoint J/S Handle 3" U-Shaped w/ Flex-ShaftI105846-99-0
Bodypoint J/S Handle 4" U-Shaped w/ Flex-ShaftI105847-99-0
Bodypoint J/S Handle Dome Shaped, RubberI105848-99-0
CHOOSE JOYSTICK MOUNT:
DescriptionPart Numbe
r
Fixed Joystick Mount - RightI10127
No Charge
Fixed Joystick Mount - LeftI10136
No Charge
Joystick Mount-Right Swing AwayI100849-99-0
Joystick Mount-Left Swing AwayI100848-99-0
Attendant Control R-net I105408-99-0
R-net Bluetooth iDevice ModuleI107350-99-0
A
llows input device commands (such as joystick nudges or switch clicks) to be used to operate
an iPhone, iPad or iPod. By assigning each input to an iOS function, users can make phone
calls, send texts and emails and access applications. Kit includes a Bluetooth iDevice Module,
an R-net Bus Cable, and two mono jack cables for direct switch inputs (switches not included).
Must be ordered with a Color JSM or Omni for mode display.
R-net Bluetooth Mouse ModuleI107367-99-0
Enables mouse control through any R-net input device. It can operate the mouse on a
computer and on select Android devices (with R-net for Android app). Kit includes a Bluetooth
Mouse Module, an R-net Bus Cable, two mono jack cables for L/R click (switches not included)
and a USB BT Adapter for user's computer. Note: BT Adapter may not work with all
computers. Must be ordered with a Color JSM or Omni for mode display.
Add a second Bluetooth Mouse ModuleI107368-99-0
A
llows R-net to simultaneously pair to a second compatible computer or Android device. Each
module is accessible through a separate R-net mode. Kit includes a unique Bluetooth Mouse
Module, an R-net Bus Cable, two mono jack cables for L/R click and a USB BT Adapter.
Output Module (IOM) for R-net Control SystemI10582
This allows a user to control an external device (ex: Communication Device, ECU, Door
Opener, etc.) through the drive input (JSM, Head Array, etc.). Each module can provide up to
4
switch closures. May require specialty cable or wiring. Up to three output modules can be
installed on one wheelchair.
Seating System
STANDARD SEATING SYSTEM:
DescriptionPart Numbe
r
Mini-Flex Seat w/ Power TiltIKOALA-MFII
Single actuator elevates into tilt (up to 25°) to allow seating system to clear base. Seating
system also includes an adjustable seat frame, adjustable backrest and legrest angle,
p
ositioning belt and one-piece footplate.
Page 3 of 10
Rev 2020-1 08/17/2020
Chairman Koala Mini-Flex
Seating System Options
Single Seat Function Control Kit for R-netI10419
For operation of a single seat function through the wheelchair electronics via the drive control.
Order with R-net electronics or remote joystick options. Please indicate below if you want push
buttons or toggles on the ICS Switchbox.
CHOOSE PUSH BUTTONS OR TOGGLES:
DescriptionPart Numbe
r
Push Buttons on Seat Function Control KitI104135-99-0
No Charge
Toggles on Seat Function Control KitI104136-99-0
Do Not Install ICS Switchbox, Send as PartI105409-99-0
No Charge
CHOOSE MOUNTING POSITION OF ICS SWITCHBOX:
DescriptionPart Numbe
r
Mount ICS Switchbox onto R-net Joystick BracketI10626
No Charge
ICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this item
is selected, the ICS Switchbox will swing away with the Joystick Module.
Mount ICS Switchbox onto Armrest - VS, KoalaI103471-99-0
No Charge
ICS Switchbox will be mounted to the end of the armrest pad. If this item is selected, the ICS
Switchbox will NOT swing away with the Joystick Module.
Mount on Left: _____ Mount on Right: _____
Mount ICS Switchbox on BackrestI106256-99-0
Mount on Left: _____ Mount on Right: _____
OPTIONAL ITEMS:
DescriptionPart Numbe
r
ICS Alternative Switchbox for R-net ElectronicsI104196-99-0
Seat function interface box that accommodates up to 8 momentary switches. Provides an
additional method for accessing the seat functions. 1/8" mini-mono switches not included.
Remote Stop System - AUS/NZ/EUI108526-99-0
Consists of a 433MHz Radio Frequency (RF) handheld transmitter and an RF receiver
mounted on the wheelchair.
Backrest Options
CHOOSE BACKREST TYPE:
DescriptionPart Numbe
r
BACKREST NOTE:
Backrest heights are measured from the seat pan to the top of the backrest shell with the
backrest set at 90°. Backrest cushions are provided with the MF Backrests only.
MF Backrest 10"W x 14"HI103185-99-0
No Charge
MF Backrest 12"W x 16"HI103186-99-0
No Charge
MF Backrest 14"W x 20"HI103187-99-0
No Charge
Tubular Backrest Frame Mini-Flex, 12" WideI10113
No Charge
Backrest canes to mount aftermarket backrest systems.
Tubular Backrest Frame Mini-Flex, 14" WideI10114
No Charge
Backrest canes to mount aftermarket backrest systems.
CHOOSE BACKREST CUSHION:
DescriptionPart Numbe
r
MX/MF Backrest Cushion, 10"W x 14"T - LeatheretteI104309-99-0
No Charge
MX/MF Backrest Cushion, 12"W x 16"T - LeatheretteI104311-99-0
No Charge
MX/MF Backrest Cushion, 14"W x 20"T - LeatheretteI104313-99-0
No Charge
MX/MF Backrest Cushion, 10"W x 14"T - Black MeshI104308-99-0
No Charge
MX/MF Backrest Cushion, 12"W x 16"T - Black MeshI104310-99-0
No Charge
MX/MF Backrest Cushion, 14"W x 20"T - Black MeshI104312-99-0
No Charge
Page 4 of 10
Rev 2020-1 08/17/2020
Chairman Koala Mini-Flex
Seat Sizing
CHOOSE SEAT TYPE:
DescriptionPart Numbe
r
MF Seat 10"W x 10"D I103188-99-0
No Charge
MF Seat 12"W x 12"D I103189-99-0
No Charge
MF Seat 14"W x 14"D I103190-99-0
No Charge
Tubular Seat Frame Mini-Flex, 12" WideI10115
No Charge
Seat frame tubes to mount aftermarket seating systems.
Tubular Seat Frame Mini-Flex, 14" WideI10116
No Charge
Seat frame tubes to mount aftermarket seating systems.
CHOOSE SEAT CUSHION:
DescriptionPart Numbe
r
Leatherette Seat Cushion MX/MF - 10"W x 10"DI104145-99-0
Leatherette Seat Cushion MX/MF - 12"W x 12"DI104146-99-0
Leatherette Seat Cushion MX/MF - 14"W x 14"DI104147-99-0
Black Mesh Seat Cushion MX/MF - 10"W x 10"DI104305-99-0
Black Mesh Seat Cushion MX/MF - 12"W x 12"DI104306-99-0
Black Mesh Seat Cushion MX/MF - 14"W x 14"DI104307-99-0
Armrest Options
CHOOSE LEFT ARMREST PAD:
DescriptionPart Numbe
r
Armrest Left, 8" LeatheretteI100770-99-0
No Charge
Armrest Left, 10" LeatheretteI100774-99-0
No Charge
CHOOSE RIGHT ARMREST PAD:
DescriptionPart Numbe
r
Armrest Right, 8" LeatheretteI100769-99-0
No Charge
Armrest Right, 10" LeatheretteI100773-99-0
No Charge
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Height Adjustable Armrest AssemblyI10137
Height Adjustable Armrest Assembly - No ChargeI10016
No Charge
No charge with power tilt and/or recline.
Legrest Options
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Footplate, Small w/ 5-12" Pan to Ftplate Adj.I101088-99-0
No Charge
Footplate, Large w/ 5-12" Pan to Ftplate Adj.I101089-99-0
No Charge
Foot Strap Kit I100599-99-0
BP Ankle Huggers, Med Side Release, Adj (Pair)I107503-99-0
This item will be sent as a part with the wheelchair. It will not be installed.
Page 5 of 10
Rev 2020-1 08/17/2020
Chairman Koala Mini-Flex
Accessories
MUST CHOOSE POSITIONING BELT:
DescriptionPart Numbe
r
Positioning Belt I100518-99-0
No Charge
CHOOSE ONE OF THE FOLLOWING:
DescriptionPart Numbe
r
MF Headrest for Koala/PS Jr - LeatheretteI100749-99-0
Must also select PN I10552.
Adj/Removable Headrest HardwareI10552
Universal Headrest AdapterI107499-99-0
Please Note: Recline is limited to 160° or less (depending on backrest height) when ordering a
Universal Headrest Adapter on a 23" or 24" tall Corpus backrest.
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Thigh Support Kit LeatheretteI100753-99-0
Must also select PN I10550.
Lateral Supports LeatheretteI100751-99-0
Must also select PN I10551.
Adj Removable - Thigh Support Hardware (Pair)I10550
Adj Removable - Trunk Support Hardware (Pair)I10551
Knee Block LeatheretteI100867-99-0
RAM X-Grip 10" Tablet Holder w/Swing Away MountI107100-99-0
Compatible with most 10" screen tablets with or without a protective case. Includes adjustable
swing away mount (I103476-99-0). Note: Customization may be required if ordered along with
an Omni.
USB Charger I107222-99-0
Provides up to 1.5A (at 5V) to charge most smartphones and tablets. The charger features an
isolated circuit design for improved safety; and by pulling power from the ICS, prevents battery
drainage when the chair is powered off. Includes mounting hardware and ICS connector. Keep
in mind charger may need to be relocated with some configurations. Mount on left armrest:
_
____ Mount on right armrest: _____
Medical Necessities Bag HooksI105805-99-0
Please Note: Recline is limited to 165° or less (depending on backrest height) when ordering
with 23" or 24" tall Ergo backrest. Custom required if ordered with a ROHO AGILITY backrest.
May ship as a part at shorter backrest heights.
Chest Harness I100598-99-0
Chest harness kit includes a standard positioning belt.
BP Shoulder Harness Medium, Front PullISH212
This item will be sent as a part with the wheelchair. It will not be installed.
Small Angle Adjustable TrayI100578-99-0
Must also select PN I10556.
Adj Removable - Tray Hardware (1 Each)I10556
Alternative Drive Systems
A
LTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:
DescriptionPart Numbe
r
Mini-Joystick for Omni - (9-pin connector)I10751
Operating Force = 13 g Neutral to Full Deflection = 5mm
Compact Joystick for Omni - (9-pin connector)I103893-99-0
Operating Force = 220 g Neutral to Full Deflection = 28mm Joystick includes two 3.5mm
mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam
Ball Knob.
Page 6 of 10
Rev 2020-1 08/17/2020
Chairman Koala Mini-Flex
Alternative Drive Systems
A
LTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:
DescriptionPart Numbe
r
Compact Joystick LITE for Omni - (9-pin connector)I103894-99-0
Operating Force = 50 g Neutral to Full Deflection = 17mm Joystick includes two 3.5mm mono
j
acks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball
Knob.
A
LT PROPORTIONAL JOYSTICK MOUNTING HARDWARE:
DescriptionPart Numbe
r
Alt. JS Swing Away Mount Kit - ArmrestI104690-99-0
Mount in front of Left Arm: _____ Mount in front of Right Arm: _____
Alt JS/Omni Combo Swing Away Mount Kit - ArmrestI107135-99-0
Used to mount Omni and Alternative Proportional Joystick to the same armrest. Includes
Swing Away Omni/Tablet Mount, with a longer mounting rod, two PERMOfix modules, one 3"
rod and one 4" rod.
Mount in front of Left Arm: _____ Mount in front of Right Arm:_____
Alt. JS Adjustable Mount Kit - Chin BoomI104143-99-0
Swing-Away / Removable Chin Boom mounted on right of backrest shell. Custom charge may
be applied if ordering lower backrest heights.
Haims Harness for Chin Control Mount, LargeI10752
For neck width up to 19cm.
Haims Harness for Chin Control Mount, SmallI10753
For neck width up to 14cm.
A
LT PROPORTIONAL JOYSTICK ACCESSORIES:
DescriptionPart Numbe
r
I104904-99-0
Dual Switches for Compact Joystick - Fixed Mount
Includes two pushbutton switches mounted on rigid arms. Switches set-up for Mode & On/
Off function. Switch operation force = 130 g
Mount at front of Joystick: _____
Mount at rear of Joystick: _____
Mount at left of Joystick: _____ Mount at right of Joystick: _____
Dual Switches for Compact Joystick - Gooseneck MntI104641-99-0
Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches are
p
ositioned on Left and Right sides of Compact Joystick. Switches set-up for Mode & On/Off
function. Switch operation force = 130 g
SIP & PUFF SYSTEMS:
DescriptionPart Numbe
r
Sip & Puff System for OmniI10573
Requires Omni Control Module. Includes breath tube kit.
Sip & Puff System with Fiber Optic Opti-StopI10574
Requires Omni Control Module. Includes breath tube kit.
Sip & Puff Kit for Total Control Head ArrayI106807-99-0
For use with Total Control Head Array. Requires Omni Control Module. Includes breath tube
kit.
Adjustable Mounting Hrdw - Sip & PuffI10762
Required when selecting PN I10573, I10574 or I106807-99-0.
Total Control Head Array
CONFIGURE HEAD ARRAY:
DescriptionPart Numbe
r
Permobil Head Array - 3-Switch SystemI106805-99-0
Features an occipital pad sensor and two stainless steel arms configured with proximity
sensors. The arms are mounted to the upper attachment points on the head array. Longer
arms are also included to extend the sensor adjustment range. ESP recommended. Choose
Omni Control Module separately.
Page 7 of 10
Rev 2020-1 08/17/2020
Chairman Koala Mini-Flex
Total Control Head Array
CONFIGURE HEAD ARRAY:
DescriptionPart Numbe
r
Program Head Array as a 5-Switch SystemI11072
No Charge
Select additional arms/sensors below and indicate the intended use of each sensor in the
Notes & Comments section. Choose Omni Control Module separately.
CHOOSE OCCIPITAL PAD SIZE (REQUIRED):
Small Occipital Pad for Head Array - 4.25"W x 3"HI105920-99-0
No Charge
Large Occipital Pad for Head Array - 6"W x 4"HI105921-99-0
No Charge
CHOOSE OCCIPITAL PAD MOUNT (REQUIRED):
Fixed Mount for Occipital Pad - Head ArrayI10847
No Charge
Adj. Swivel Mount for Head Array Occipital PadI105936-99-0
Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms.
CHOOSE HEAD ARRAY MOUNT HARDWARE (REQUIRED):
Stealth TWB480 Backrest Mounting Hdwr with LinksI105927-99-0
Please select the length of the vertical stem below:
Standard length (10"): _____ Short length (6"): _____
Stealth TWB480 Backrest Mtng Hdwr with FlipbackI105941-99-0
Stealth HMO475 Backr Mtng Hdwr w 17mm BallI105925-99-0
SELECT ADDITIONAL LEFT ARM PACKAGE (OPTIONAL):
Add Left Lateral Arm w
Proximity SensorI10976
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Left Lateral Arm w Egg SwitchI10977
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Left Lateral Arm w Pad (No Sensor or Switch)I10978
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
SELECT ADDITIONAL RIGHT ARM PACKAGE (OPTIONAL):
Add Right Lateral Arm w Proximity SensorI10979
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Right Lateral Arm w Egg SwitchI10980
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Add Right Lateral Arm w Pad (No Sensor or Switch)I10981
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Alt Drive Systems Setup
CHOOSE OMNI
(
REQUIRED
)
:
DescriptionPart Numbe
r
Omni2 Control Module for R-net - KoalaI108609-99-0
Two-section design features 3.5" VGA high resolution display, USB charger port, built in IR
control and integrated Bluetooth technology for control of up to 4 Bluetooth devices. Must also
select mounting hardware below. Please specify which type of alternative drive input device
you will be using. Input Device:______________________________
Adjustable Swing-Away Hardware - Omni/TabletI103476-99-0
Mount in front of Left Arm: _____ Mount in front of Right Arm: _____
Page 8 of 10
Rev 2020-1 08/17/2020
Chairman Koala Mini-Flex
Alt Drive Systems Setup
CHOOSE MOUNTING POSITION OF SEAT CONTROL SWITCHBOX
:
DescriptionPart Numbe
r
Mount Seat Control Switchbox on BackrestI10080
No Charge
Alt Drive Accessories
PERMOFIX MOUNTING SOLUTIONS:
DescriptionPart Numbe
r
Proximity Sensor + Swivel Assm - Not MountedI105907-99-0
Only available with the Total Control Head Array. Swivel assembly allows sensor to be
mounted with PERMOfix or directly to lateral arm of Total Control Head Array. Since Proximity
Sensors require power, they CANNOT be used as On/Off switches.
Egg Switch + Swivel Mount Assm - Not MountedI105919-99-0
Swivel assembly allows switch to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
Solid Lateral Pad+Swivel Joint - Not MountedI105912-99-0
Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
Oval Plate + Swivel Assm - No Switch - Not MountedI106675-99-0
Blank plate provides mounting option for Micro Lite, Buddy Button or other switch options.
Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
OPTIONAL ITEMS:
DescriptionPart Numbe
r
Microlight Switch Qty:____I101769-99-0
Buddy Button Qty:____I101767-99-0
Egg Switch Black Qty: _____I106293-99-0
Mini Cup Switch Qty:____I101771-99-0
Proximity Switch
Qty:____I107500-99-0
Mini Joyswitch 5 Switch OC for Omni - (9-pin)I107495-99-0
Dome Switch, Backrest Mnt w Gooseneck Qty: _____I10772
Mount on Left: _____ Mount on Right: _____
Mounts at top of backrest shell. Custom charge may be applied if ordering with short backrest
heights. Kit Includes: One PERMOfix joint with Flat Plate, two PERMOfix joints with 45° swivel
adjustment, one 150mm rod, one 200mm rod and one 225mm gooseneck switch with 1.2m
cable and mounting clamp.
Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty:____I10846
Mount on Left: _____ Mount on Right: _____
w 90° Swing-Away Function. Mounts at top of back. Custom charge applies if ordered with
short back. Kit Includes: One PERMOfix joint with Flat Plate, one PERMOfix joint with 45°
swivel adjustment, two 6" rods, one 90° Swing-Away joint, one 9"
3.5mm Ext. Cable for Sensor/Switch, 0.3m LongI105935-99-0
3.5mm Ext. Cable for Sensor/Switch, 1m LongI105931-99-0
3.5mm Ext. Cable for Sensor/Switch, 2m LongI105932-99-0
3.5mm Ext. Cable for Sensor/Switch, 3m LongI105933-99-0
3.5mm Y-splitter Cable for Sensor/SwitchI105934-99-0
A
llows two Proximity Sensors/Mechanical Switches to connect to the same direction jack.
Page 9 of 10
Rev 2020-1 08/17/2020
Chair Order Polic
y
:
You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms. The order cannot be processed
without the following:
-A client name or code, the client’s measurements, the client’s weight
-The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil is not
responsible for configuration or size discrepancies resulting from customer errors on the order form.
-Order confirmations will be provided by Permobil summarizing the items selected. Please review this carefully.
-Once the order is shipped, any changes are subject to the returns policy and may be prohibited.
Order Acknowled
g
ement:
I, _________________________, am an agent of the medical equipment provider named on this order form and I have the authority to contract for the
purchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete and
accurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returns policy
and may carry additional charges.
Signed:
Printed Name:
Title:
Date:
NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if ordered with the wheelchair. Any
parts ordered for service or future alterations will carry different pricing and warranty.
Additional Order Instructions:
Page 10 of 10
Rev 2020-1 08/17/2020
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Chairman Koala Mini-Flex (Accident Compensation Corporation New Zealand)

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Completed 16 January 2022

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