Tilting Chair Order form

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Hello there, please try to fill this form with as much detail as possible. There is a note section at the end of the questionaire to add any additional information.0

For feedback, please email us at info@powerplusmobility.org or call us at Telephone (905)-614-0333 Toll Free 1-(855)-614-0333.

Our website: https://powerplusmobility.com
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Name* This field is required.
First Name
Last Name
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Who is your local Power Plus Mobility Rep:* This field is required.
Brian Johnson (South Central and Western Ontario)
Leo Stewart(Northern & Eastern Ontario)
Loui Triantafillou (GTA and Surrounding Area)
Mike Dangerfield (Western Canada)
Craig Royal (British Columbia)
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Client company name:* This field is required.Enter client company name below
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TAG:* This field is required.Who is ordering this product from the Company?
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Frame colour* This field is required.
STPB Tilt Frame - Black $2699
STPS Tilt Frame - Silver $2699
STPC Tilt Frame - Custom $3099
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Custom frame colour. Please enter the colour below:* This field is required.Type custom colour information
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Client weight:* This field is required.
STPWA Up to 250Lbs N/C
STPWAMF Exceeds 250Lbs $ 730
STPWAMG Exceeds 350Lbs $992
STPWAMH Exceeds 400Lbs (Max 600Lbs) $1110
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Seat width:* This field is required.
STPSW17 Seat Width 17" N/C
STPSW18 Seat Width 18" N/C
STPSW19 Seat Width 19" $399
STPSW20 Seat Width 20" $399
STPSWC Custom Seat Width $399
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If custom seat width. please enter the seat width below:* This field is required.Type custom width information
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Seat depth:* This field is required.
STPSD16 Seat Depth 16" N/C
STPSD17 Seat Depth 17" N/C
STPSD18 Seat Depth 18" N/C
STPSD19 Seat Depth 19" $265
STPSD20 Seat Depth 20" $265
STPSDC Custom Seat Depth $265
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If custom seat depth. Please enter the seat depth below:* This field is required.
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Foot rest and foot plates:* This field is required.
STPOFST Offset Foot Rest N/C
STPF6A 60 Degree Hanger N/C
STPF7A 70 Degree Hanger N/C
STPF8A 80 Degree Hanger N/C
STPEA Elevating Legrest $404
STPAL Articulating L/R $450
STPEB Elevating Legrest System $450
STPPPL Plastic N/C
STPPXL Extra Large $150
STPPAF Angle Adjustable Footplates $240
STPFRCH Padded Footplates $88
STP1FB One Piece Foot Board $80
STPNLS Nylon Leg Strap Padded $60
STPNLSC Nylon Leg Strap Custom $120
STPCSL Contracture Sling $240
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Size of custom nylon leg strap?* This field is required.
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Pivot style or pin style?* This field is required.
Pivot
Pin
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Back type:* This field is required.
STPAB1 Angle Adjustable Back N/C
STPENDO Endomorph Canes N/C
STPRBK Recline Kit $560
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Width of endomorph canes?* This field is required.
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Headrest options:* This field is required.
STPMAHF Multi-Axis Hardware Complete with Large Pad $512
STPMAHFXL Multi-Axis Hardware Complete with Flex Large $512
STPMAHKP Multi-Axis Hardware Complete with Medium Pad $512
STPMAHFXS Multi-Axis Hardware Complete with Flex Medium $512
STPMAHFT Multi-Axis Hardware Complete with Small $512
STPUPHT219 Contour Headrest Complete with Swivel Hardware $433
STPUPHT218 Contour Headrest with Std. Assembly (1/2") $292
STPUPHT217 Contour Headrest with Std. Assembly (3/4") $292
STPUHA Universal Hardware Adaptor (Adaptor only) $57
STPMAHGA-P Multi Axis with Headrest Plate (No Pad) $255
No Headrest
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Arm rests:* This field is required.
STPTA T-Arm Ht. Adj./ Removable $240 (Standard 10 - 14 inches)
STPFA Flip Back Ht. Adj./ Removable $340 (Standard 10 - 14 inches)
STPTAS T-Arm Ht. Adj./ Removable $240 (Short 7 - 11 inches)
STPFAS Flip Back Ht. Adj./ Removable $340 (Short 7 - 11 inches)
STPGWAPF Gel Waterfall Arm Pads $180
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Rear wheels:* This field is required.
STPRWT0 20” Solid Treaded Tire N/C
STPRWT2 22” Solid Treaded Tire N/C
STPRWT4 24” Solid Treaded Tire N/C
STPRWT12 12" Solid Tire N/C (STF 13-19 inches)
STPRWT12I 12" Solid Tire Inside Mount $120 (STF 17-19 inches)
STPRWT16 16" Solid Tire N/C
STPRWA2 22” Air Tire $120
STPRWA4 24” Air Tire $120
STPAQR Axles – Quick Release $120
STPHRT Narrow Handrim Config. (1/2" less) N/C
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Seat to floor specifications (STF):* This field is required.
STF = SL 12.25, R.Wheel = 20, Caster = 5, Fork = XL SHORT
STF = SL 13.00, R.Wheel = 20, Caster = 5, Fork = XL SHORT
STF = LL 13.75, R.Wheel = 20, Caster = 5, Fork = XL SHORT
STF = L 14.50, R.Wheel = 20, Caster = 6, Fork = SHORT
STF = L 14.50, R.Wheel = 22, Caster = 5, Fork = SHORT
STF = L14.50, R.Wheel = 22, Caster = 6, Fork = SHORT
STF = LH 15.25, R.Wheel = 20, Caster = 5, Fork = SHORT/LONG
STF = LH 15.25, R.Wheel = 20, Caster = 6, Fork = SHORT/LONG
STF = LH 15.25, R.Wheel = 22”, Caster = 5”, Fork = SHORT/LONG
STF = LH 15.25, R.Wheel = 22, Caster = 6, Fork = SHORT/LONG
STF = SH 16.00”, R.Wheel = 22, Caster = 6, Fork = LONG
STF = MH 16.75”, R.Wheel = 22”, Caster = 6”, Fork = LONG
STF = H 17.50, R.Wheel = 22, Caster = 6, Fork = LONG
STF = H 17.50, R.Wheel = 22, Caster = 8, Fork = LONG
STF = H 17.50, R.Wheel = 22, Caster = 6, Fork = LONG
STF = H 17.50, R.Wheel = 24, Caster = 8, Fork = LONG
STF = A 18.25, R.Wheel = 24, Caster = 8, Fork = LONG
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Caster size:* This field is required.
STPFC1A 5” X 1.25” Caster N/C
STPFC1B 6” X 1.25” Caster N/C
STPFC1C 8” X 1.25” Caster N/C
STPFC2A 5” X 1.75” Caster (Soft Roll) $80
STPFC2B 6” X 1.75” Caster $80
STPFC2C 8” X 1.75” Caster $80
STPFC4B 6” X 2 Caster (Steel Fork) $80
STPFC4C 8” X 2 Caster (Steel Fork) $80
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Wheel lock options:* This field is required.
STPALPH Aluminium Push To Lock N/C
STPALPL Aluminium Pull To Lock N/C
STPSTPH Steel Push To Lock N/C
STPSTPL Steel Pull To Lock N/C
STPBRXC 4” Brake Extension N/C
STPBRXA 6” Brake Extension N/C
STPBRXB 9” Brake Extension $130
STPATTBRX Attendant Brakes $240
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Seating - backs:* This field is required.Note: Please refer to the seating booklet for custom sizes
STPBK01 RELAX Gentle Fit Back $544
STPBK02 RELAX Full Fit Back $608
STPBK03 RELAX Snug Fit Back $700
STPBK04 RELAX Form Fit Back No Laterals $820
STPBK06 RELAX Form Fit Back Gentle Laterals $820
STPBK07 RELAX Form Fit Back Full Laterals $820
STPBK05 RELAX Form Fit Back Snug Laterals $820
STPBK10 RELAX Spiral Fit Back Gentle Laterals $832
STPBK09 RELAX Spiral Fit Back Snug Laterals $832
STPBK11 RELAX Spiral Fit Back Full Laterals $832
STPTAB RELAX Tension Back Upto 18” $140
STPTAB+ RELAX Tension Back Over 18” $240
STPBGL1 Half Overlay Gel (3 Piece) $348
STPBGL2 Full Overlay Gel (6 Pieces) $696
STPPSTP Pin Extension (1" Extension) $40
STPBK12 Custom Width $176
STPBK13 Custom Height $176
No Back
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Enter back width and height:* This field is required.
Width
Height
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Enter custom width below:* This field is required.Custom width
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Enter custom height below:* This field is required.Custom height
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Seating - cushions:* This field is required.Note: Please refer to the seating booklet for custom sizes
STPC01 RELAX Soft Cushion $480
STPC02 RELAX Comfy Cushion $624
STPC03 RELAX Firm Cushion $784
STPCGL1 Half Overlay Gel (1 Piece) $116
STPCGL2 Full Overlay Gel (2 Pieces) $232
STPCCL Contoured Leg Channel (Bolster) Std. $180
STPCCLC Contoured Leg Channel (Bolster) Custom ( *Note: Please refer to the Seating Booklet for custom sizes) $320
No Cushion
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Accessories:
STPC00 Extra Cushion Cover $99
STPSBA Seat Belt (Auto Style) $26
STPSBAP Seat Belt (Padded) $56
STPSBA4P Seat Belt (4 Point Padded) $130
STPTRA Full Padded Tray Locking $280
STPTRB Full Padded Tray Slide On $280
STPTRC Full Plastic Tray   ABS Black or Clear $280
STPTRD Half Padded Left Tray $240
STPTRE Half Padded Right Tray $240
STPTRF Half Left Tray   ABS Black or Clear $240
STPTRG Half Right Tray   ABS Black or Clear $240
STPTDFB Transport Tie Downs Front $85
STPTDRB Transport Tie Downs Rear $85
STPOXY Oxygen Tank Holder $195
STPIVA Adjustable I V Pole $130
STPCHPT-L Left Arm Trough Tray $400
STPCHPT-R Right Arm Trough Tray $400
STPLATB Lateral Bite out $180
STPADD8 8" Adductor $164
STPADD10 10" Adductor $164
STPADD12 12" Adductor $164
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Lap tray material:* This field is required.
ABS Black
Clear
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Notes:* Please enter any other additional information or comments you may have for this quote below
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Unique ID
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Sub total
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What is your discount structure percentage?Please only enter the value of the discount. e.g. 50% would be value 50
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Total with discount
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Enter email to receive a confirmation as well as a contact method if we needed more information:* This field is required.
example@example.com
Confirm Email
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