Order!Form!
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DME$Provider$Information$$
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Company!Name:!_________________________________________!!!!Contact!Name:!______________________________!
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Phone!Number:!______________________________!!!!!!!!!!Email:!!_______________________________________________!
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Shipping!Address:!_________________________________________________________________________________________!
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Client$Information$
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Client’s!Name:!________________________________________!!Client’s!Diagnosis:!______________________________!
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Client’s!Height:!!_____________!!!Client’s!Weight:!!!_____________!
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Make!and!Model!of!Client’s!Wheelchair:!!___________________________________________________________________!
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Frame!Width:!!____________________!!Frame!Depth:!_____________________!!!Hip!Angle:!______________________!
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**$Will$You$be$Sending$a$Plaster$Cast$Mold?$!! Yes$$[$$$$]$$$$$$$$$$$No$$[$$$$]$
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Measurements!in!Inches:!
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Matrix$Product/Line$Item$to$Appear$on$Estimate:$$***!See!following!pages!for!size!chart!and!MSRP$
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Page!2:!CUSTOM!MOLDED!SEAT/BACK!COMPLETE!ASSEMBLY.$$Specify!Size:!________________________$
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Page!3:!BACKS!ONLY!COMPLETE!ASSEMBLY.!!Specify!Size:!_____________________________________________!
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Page!3:!ADDITIONAL!MATRIX!ACCESSORIES. Specify:!!__________________________________________________
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Heads$First$
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Page!4:!Headrest.!!Specify!Type:!!____________________________!!Headrest!Size!(Adult!or!Child):!!!__________!
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Page!4:!!Headrest!Mounting!Hardware!(Attach!to!Canes!or!Back?):!______________________________________!
Email:[email protected]!Fax:!800898689319!Call:!800898689319!
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**$IMPORTANT$REMINDERS$ABOUT$PLASTER$CAST$MOLDS:$
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• Please!indicate!any!necessary!special!notes!(areas!of!flexibility,!extra!rows!etc…)!on!the!cast.!
• If!hip/shoulder!belt!slits!are!needed!in!the!cover,!please!indicate!appropriate!placement!on!
the!plaster!cast.!
• Remember!to!draw!a!line!where!you!would!like!the!Matrix!custom!seat!and!back!to!end.!
• Remember!to!also!write!the!TOP!of!the!cast,!the!client’s!name!and!company!name.!
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MATRIX CUSTOM MOLDED SEAT AND BACK COMPLETE ASSEMBLY
Product description
MSRP
Size 1 Complete Assembly (seat, cover and hardware)
Size 1 Matrix Sheet, Child, 26" x 18"
Pivot to mount Matrix to client chair (6)
Size 1 Full Cover
Size 2 Complete Assembly (seat, cover and hardware)
Size 2 Matrix Sheet, Adolescent, 34" x 20"
Pivot to mount Matrix to client chair (6)
Size 2 Full Cover
$4,997.19
!$2,385.81!
$2,050.88
$560.50!!
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$6,033.55
!$3,157.42!
$2,050.88
$825.25!!
Size 3 Complete Assembly (seat, cover and hardware)
Size 3 Matrix Sheet, Small Adult, 42" x 22"
Pivot to mount Matrix to client chair (8)
Size 3 Full Cover
$7,790.92
!$4,031.41!
$2,734.51
$1,025.00!!
Size 4 Complete Assembly (seat, cover and hardware):
Size 4 Matrix Sheet, Medium Adult, 50" x 24"
Pivot to mount Matrix to client chair (8)
Size 4 Full Cover
$9,133.38
$5,023.22
$2,734.51
$1,375.65!!
Size 5 Complete Assembly (seat, cover and hardware):
Size 5 Matrix Sheet, Large Adult, 46" x 30"
Pivot to mount Matrix to client chair (8)
Size 5 Full Cover
$9,927.76
$5,642.90
$2,734.51
$1,550.35!!
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Email:[email protected]!Fax:!800898689319!Call:!800898689319!
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MATRIX BACKS COMPLETE ASSEMBLY
Product description
MSRP
Size 1 Back Complete Assembly (back, cover and hardware):
Size 1 Back, Child 17” h X 24“ w (Hip w 11”)
Pivot to mount Matrix to client chair (2)
Size 1 Back Cover
$2,971.11
$2,012.37
$683.63
Size 2 Back Complete Assembly (back, cover and hardware):
Size 2 Back, Adolescent 19” h X 28” w (Hip 14”)
Pivot to mount Matrix to client chair (2)
Size 2 Back Cover
$3,359.86
$2,260.48
$683.63
Size 3 Back Complete Assembly (back, cover and hardware):
Size 3 Back, Small Adult 20” h X 28” w (Hip 14”)
Pivot to mount Matrix to client chair (4)
Size 3 Back Cover
$4,473.00
$2,530.74
$1,367.26
Size 4 Back Complete Assembly (back, cover and hardware):
Size 4 Back, Med Adult 21” h X 31” w (Hip 14”)
Pivot to mount Matrix to client chair (4)
Size 4 Back Cover
$4,985.15
$2,732.44
$1,367.26
Size 5 Back Complete Assembly (back, cover and hardware):
Size 5 Back, Large Adult 23” h X 33” w (Hip 14”)
Pivot to mount Matrix to client chair (4)
Size 5 Back Cover
$5,445.56
$3,067.58
$1,367.26
$275.11!!
$415.75!!
$575.00!!
$885.45!!
$1,010.72!!
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ADDITIONAL MATRIX ACCESSORIES
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Product description
Pivot to mount Matrix to client chair
Ball Stand Off hardware to mount Matrix to client chair
Carbon fiber reinforcement strips (cladding) 1 " W (1) 12 “ L
MSRP
$341.81
$341.81
$135.00
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Email:[email protected]!Fax:!800898689319!Call:!800898689319!
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HEADS$FIRST$O$Headrests$
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Panda Bear Complete with Cover
Penguin Complete with Cover
Penguin
Penguin Bilateral
Penguin Right
!$472.33!!
!$584.06!!
!$543.39!!
Penguin Left
!$543.39!!
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Black Bear Complete with Cover
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MSRP
Panda Bear
!$606.30!!
Panda Bear Bilateral
!$828.07!!
Panda Bear Right
!$797.89!!
Panda Bear Left
!$797.89!!
Panda Bear, Feet
!$839.16!!
Panda Bear Bilateral + Feet
!$901.73!!
Panda Bear Right + Feet
!$880.43!!
Panda Bear Left + Feet
!$880.43!!
Butterfly Complete with Cover
Butterfly
Butterfly Bilateral
Butterfly Right
Butterfly Left
MSRP
!$457.78!!
!$661.72!!
!$557.81!!
!$557.81!!
MSRP
Black Bear
!$589.47!!
Black Bear, Bilateral Arms
!$788.94!!
Black Bear Right
!$689.24!!
Black Bear Left
Black Bear, Feet
!$689.24!!
!$797.89!!
Black Bear, Bilateral Arms + Feet
!$859.79!!
Black Bear, Right + Feet
!$832.28!!
Black Bear, Left + Feet
!$832.28!!
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Headrest$Mounting$Hardware!
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Product description
Headrest hardware - multi axis w/ 1" bar
Headrest hardware - multi axis with flip down
Matrix headrest mount to back cane, W/1" ball.
MSRP
$150.00
$150.00
$675.84
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Email:[email protected]!Fax:!800898689319!Call:!800898689319!
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MSRP