Fillable (E2622) $510 ACCOUNT INFORMATION CG Air Single Valve

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(E2622) $510 ACCOUNT INFORMATION CG Air Single Valve

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(E2622) $510
(E2622) $564
(E2622) $535
CGA2VSCxxxx-x
NEW
(E2624) $510
CGA2V3Dxxxx-x
NEW
(E2624) $564
CGA2VICxxxx-x
NEW
(E2624) $535
16" x 16" Qty: ______
16" x 18" Qty: ______
18" x 16" Qty: ______
(E2623) $510
(E2623) $564
(E2623) $535
CGA2VSCxxxx-x
NEW
(E2625) $510
CGA2V3Dxxxx-x
NEW
(E2625) $564
CGA2VICxxxx-x
NEW
(E2625) $535
22" x 22" Qty: ______
24" x 20" Qty: ______
(E2623) $610
(E2623) $680
(E2623) $625
CGA2VSCxxxx-x
NEW
(E2625) $610
CGA2V3Dxxxx-x
NEW
(E2625) $680
CGA2VICxxxx-x
NEW
(E2625) $625
28" x 20" Qty: ______
28" x 22" Qty: ______
28" x 24" Qty: ______
(E2619) $130
(E2619) $150
(E2619) $130
$31
$149
□ 2" (Only available in Single Valve) □ 3" □ 4"
□
CGAPK3 CG Air Patch Kit - 3 Patches (Includes alcohol prep pads and adhesive)
□
CGAPK15 CG Air Patch Kit - 15 Patches (Includes alcohol prep pads and adhesive)
CGASCxxxx-x
CGA3Dxxxx-x
CGAICxxxx-x
Standard 2-way Stretch Cover. Specify Dimensions: W _____" D _____" H_____"
3D Mesh Cover. Specify Dimensions: W _____" D _____" H_____"
Incontinence Cover. Specify Dimensions: W _____" D _____" H_____"
□
□
□
26" x 24" Qty: ______ 30" x 24" Qty: ______
30" x 20" Qty: ______ Other, specify __________ Qty: ______
26" x 22" Qty: ______ 30" x 22" Qty: ______
DUAL (2) VALVEDUAL (2) VALVE
CG Air Single Valve (Includes a Incontinence Covers)
Other, specify __________ Qty: ______
22" x 20" Qty: ______ 24" x 24" Qty: ______
SINGLE (1) VALVE
CG Air Single Valve (Includes a Incontinence Covers)
CGA1V3Dxxxx-x
SELECT CELL HEIGHT
CG Air Single Valve (Includes a Standard 2-way Stretch Covers)
□
CGA1V3Dxxxx-x
22" x 18" Qty: ______ 24" x 22" Qty: ______
CG Air Single Valve (Includes a Standard 2-way Stretch Covers)
□
CG Air Dual Valve (Includes a Incontinence Covers)
16" x 14" Qty: ______ Other, specify __________ Qty: ______
CG Air Single Valve (Includes a 3D Mesh Covers)
□
CGA1VICxxxx-x
14" x 14" Qty: ______
26" + WIDE
□
22" to 24" WIDE
SINGLE (1) VALVE
20" x 20" Qty: ______
□
20" x 16" Qty: ______
□ 2" (Only available in Single Valve) □ 3" □ 4"
CGA1VSCxxxx-x
P.O. # or Quote:
Shipping Name:
Billing Name:
Email Address:
ORDERING INFORMATION: PHONE: (888) 453-0311, FAX: (877) 501-8458, EMAIL: info@amylior.com
ACCOUNT INFORMATION
OCTOBER 2020
Ship Address:
Contact Name:
20" x 18" Qty: ______
CG Air Dual Valve (Includes a Incontinence Covers)
DUAL (2) VALVE
Fax Number:
Phone Number:
Zip Code:
City:
State:
CG Air THERAPEUTIC SEAT CUSHION
□
CG Air Dual Valve (Includes a 3D Mesh Covers)
□
User Name or Number:
□
18" x 20" Qty: ______
18" x 18" Qty: ______
□
□
□
14" x 16" Qty: ______
SELECT CELL HEIGHT
□ 2" (Only available in Single Valve) □ 3" □ 4"
CG Air Single Valve (Includes a 3D Mesh Covers)
14" to 20" WIDE
CGA1VSCxxxx-x
CGA1V3Dxxxx-x
CGA1VICxxxx-x
CG Air Single Valve (Includes a Standard 2-way Stretch Covers)
SINGLE (1) VALVE
CG Air Single Valve (Includes a Incontinence Covers)
CG Air Dual Valve (Includes a Standard 2-way Stretch Covers)
□
CG Air Dual Valve (Includes a 3D Mesh Covers)
REPLACEMENT COMPONENTS
26" x 20" Qty: ______
SELECT CELL HEIGHT
CGA1VSCxxxx-x
CGA1VICxxxx-x
CG Air Single Valve (Includes a 3D Mesh Covers)
□
CG Air Dual Valve (Includes a 3D Mesh Covers)
CG Air Dual Valve (Includes a Standard 2-way Stretch Covers)
□
CG Air Dual Valve (Includes a Incontinence Covers)
□
CG Air Dual Valve (Includes a Standard 2-way Stretch Covers)
□
DUAL (2) VALVE
□
MKT.F35
Specifications are subject to change without notice. Copyright @ 2020, Amylior Inc. (October 2020) Amylior CG Air (Rev.3)
Page 1 of 3
CLEAR FORM
SEND BY EMAIL
DELUXE
CGAPK3 CG Air Patch Kit - 3 Patches (Includes alcohol prep pads and adhesive)
CGAPK15 CG Air Patch Kit - 15 Patches (Includes alcohol prep pads and adhesive)
24681012141618202224262830
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
□
$149
STEPS TO FOLLOW TO FILL OUT THE
MATRIX
1. Specify the requested size of the cushion
W ________" x D ________"
2. Specify the cell height ________". If
different heights are needed, indicate 2, 3 or
4 in each square to show each cell height.
3. Specifiy the number of valves as well as
the valve position by writing a "V". If more
than one valve is required, draw a line to
show the compartment area.
4. If cells are not required, indicate an "X" in
the square.
ORDERING INFORMATION: PHONE: (888) 453-0311, FAX: (877) 501-8458, EMAIL: info@amysystems.com
ACCOUNT INFORMATION
P.O. # or Quote:
Billing Name:
OCTOBER 2020
Contact Name:
Shipping Name:
Email Address:
Ship Address:
Phone Number:
City:
Fax Number:
State:
User Name or Number:
Zip Code:
CG Air DELUXE - CUSTOM THERAPEUTIC SEAT CUSHION
14" to 20" WIDE
(Build as per specifications below)
□
CGADLX10-20-SC CG Air Deluxe (Includes a Standard 2-way Stretch Cover) -
Below 22" Wide
(E2624) $510
□
CGADLX10-20-3D CG Air Deluxe (Includes a 3D Mesh Cover) -
Below 22" Wide
(E2624) $564
□
CGADLX10-20-IC CG Air Deluxe (Includes an Incontinence Cover) -
Below 22" Wide
(E2624) $535
22" to 24" WIDE
(Build as per specifications below)
□
CGADLX22-24-SC CG Air Deluxe (Includes a Standard 2-way Stretch Cover) -
22" to 24" Wide
(E2625) $510
□
CGADLX22-24-3D CG Air Deluxe (Includes a 3D Mesh Cover) -
22" to 24" Wide
(E2625) $564
□
CGADLX22-24-IC CG Air Deluxe (Includes an Incontinence Cover) -
22" to 24" Wide
(E2625) $535
26" + WIDE
(Build as per specifications below)
□
CGADLX26+-SC CG Air Deluxe (Includes a Standard 2-way Stretch Cover) -
26" Wide or more
(E2625) $610
$680
□
CGADLX26+-IC CG Air Deluxe (Includes an Incontinence Cover) -
26" Wide or more
(E2625) $625
□
CGADLX26+-3D CG Air Deluxe (Includes a 3D Mesh Cover) -
26" Wide or more
(E2625)
□
CGA3Dxxxx-x 3D Mesh Cover. Specify Dimensions: W _____" D _____" H_____" (E2619) $150
REPLACEMENT COMPONENTS
□
CGAICxxxx-x Incontinence Cover. Specify Dimensions: W _____" D _____" H_____" (E2619) $130
CG Air DELUXE - CUSTOM ORDER MATRIX
□
$31
WIDTH - FRONT OF CUSHION
DEPTH
THE COLORS ARE USED TO SHOW THE DIFFERENT
CELL HEIGHT POSSIBILITIES
□
CGASCxxxx-x Standard 2-way Stretch Cover. Specify Dimensions: W _____" D _____" H_____" (E2619) $130
MKT.F35
Specifications are subject to change without notice. Copyright @ 2020, Amylior Inc. (October 2020) Amylior CG Air (Rev.3)
Page 2 of 3
18"
OCTOBER 2020
SIZING CHART
CG AIR OTHER MANUFACTURERS
18"
10" 5 10" 10"
12" 6 12" 12"
# OF CELLS
SURFACE OF
CELLS
WIDTH OR
DEPTH
# OF CELLS
6
7 14" 14"
SURFACE OF
CELLS
58.75"
11" 5 10" 11" 6 10.50"
WIDTH OR
DEPTH
10.50"
13" 6 12" 13" 7 12.25"
8 14"
15" 7 14" 15" 8 14"
14"
16" 8 16" 16" 9 15.75"
17" 8 16" 17" 9 15.75"
10 17.5"
19" 9 18" 19" 10 17.5"
18" 9
20" 10 20" 20" 11 19.25"
21" 10 20" 21" 12 21"
22" 11 22" 22" 12 21"
23" 11 22" 23" 13 22.75"
24" 13 22.75"
25" 12 24"
www.amylior.com / info@amylior.com / Phone: 888 453-0311 / Fax: 877 501-8458
25" 14 24.5"
MEETS FLAMABILITY STANDARDS CAL TB 117-2013
24" 12 24"
MKT.F35
Specifications are subject to change without notice. Copyright @ 2020, Amylior Inc. (October 2020) Amylior CG Air (Rev.3)
Page 3 of 3
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(E2622) $510 ACCOUNT INFORMATION CG Air Single Valve

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Completed 9 May 2021

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