Helio Order Form - British Columbia

519, J‐Oswald Forest, suite 101 Saint‐Roch‐de‐l'Achigan, QC, Canada J0K 3H0 T.450 588‐6555 1 866 650‐6555 F.450 588‐0200 www.motioncomposites.com

May 1st, 2011

ORDER FORM

User manual:

Account :

PO :

□ English □ French Ship to :

Vendor :

Name :

Date :

Address :

Ordered by :

City:

Marked for :

Postal Code :

Province : Phone :

Description 1

WMA3QM005 HELIO /WAMC

Ultralight manual folding helio wheelchair (1)

FRAME COLOR 2 Onyx black □ Summit white □ Sapphire blue □ Ruby red □

3 Custom color HFC1 4 Clear coated 3k carbon fiber HFC2 SEAT WIDTH & DEPTH 5 Seat width 14” □ 15” □ 16” □ 17” □ 18” □

6 HSW1 Seat width 19” □ 20” □ WAMA 7 Seat depth 14” □ 15” □ 16” □ 17” □ 18” □

8 Seat depth 19” □ 20” □ WAMB HSD1 FRAME SIZE (See drawing at the end of order form) 9 Regular frame

10 Extended frame + 1” (2) □ Extended frame + 2” (3) □

notes : (2) : Not available with 20’’ seat depth (1) : Maximum weight limit: 250lbs (3) : Not available with 19’’ and 20’’ seat depth

STRAIGHT BACK 11 Lightweight carbon fiber back cane

12 Select height: 9” – 12” □ 12” – 15” □ 15” – 18” □ 18” – 21” □ Set height to : _____________ (measured from seat sling to top of back upholstery /see drawing at the end of order form)

8° BEND BACK 13 Aluminum back cane HBA1 14 Lightweight carbon fiber back cane HBA5 15 Select height: 13½” – 15” □ 15” – 18” □ 18” – 21” □ Set height to : _____________ (measured from seat sling to top of back upholstery /see drawing at the end of order form)

ADJUSTABLE ANGLE BACK 16 Lightweight carbon fiber back cane HBA2 17 Select height: 12” – 15” □ 15” – 18” □ 18” – 21” □ 18 Select back cane angle: 85° □ 90° □ 95° □ 100° □ 105° □ 110° □ Set height to : _____________ (measured from seat sling to top of back upholstery /see drawing at the end of order form)

PUSH HANDLES 19 Push handles

20 Omit push handle

21 Folding stabilizer bar* (Available with push handles only) HBA3

$3100

□

NC $300 $450

□ □ □

NC $285 NC $215

□ □ □ □

NC NC

□ □

NC

□

$80 $140

□ □

$236

□

NC NC $175

□ □ □

*Suggested with 19” or 20” seat width

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HELIO_CANADA‐BC_V0.09aEN

519, J‐Oswald Forest, suite 101 Saint‐Roch‐de‐l'Achigan, QC, Canada J0K 3H0 T.450 588‐6555 1 866 650‐6555 F.450 588‐0200 www.motioncomposites.com

May 1st, 2011

Description SEATING UPHOLSTERY 22 Nylon seat sling 23 Omit seat sling SEATING CUSHION 24 2’’ cushion 25 3’’ cushion 26 Omit cushion BACK UPHOLSTERY 27 Slip on back upholstery 28 Adjustable tension back upholstery 29 Omit back upholstery

FLIP BACK ARMREST 30 Desk length 31 Full length Height 32 6” – 8” □ 8” – 10” □ 9½” – 12” □ 12” – 14” □

‘’T’’ ARMREST 33 Desk length 34 Full length Height 35 6” – 8” □ 8” – 10” □ 9½” – 12” □ 12” – 14” □

SWING AWAY ARMREST Height adjustable 8” ‐ 12” 36 Tubular arm pad 37 Desk length arm pad 38 Rigid side guard

FOOTREST 39 60° swing away footrest, 14” – 18” length adjustable 40 70° swing away footrest, 14” – 18” length adjustable 41 90° swing away footrest, 14” – 18” length adjustable 42 Elevating legrest with calf pad, 14” – 18” length adjustable 43 Length modification, less than 14” or over 18” 44 Direct mount (Footplate(s) mounted to the front frame) Set length to :_______________

STUMP SUPPORT Height and angle adjustable 45 Swing away stump support, 8” x 11” left □ right □

FOOTPLATES 46 Standard (Composite) 47 Adjustable angle oversize (Aluminum) 48 One piece adjustable angle flip‐up 49 Length adjustable heel loop 50 Length adjustable toe strap 51 Calf strap 52 Padded calf strap

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NC NC

□ □

HSC1 HSC2

$115 $135 NC

□ □ □

WAMD/WAME HBU1 HBU2

NC $162 $‐15

□ □ □

HAR1 HAR2

$348 $348

□ □

HAR3 HAR4

$280 $280

□ □

HAR5 HAR6 HAR7

$250 $250 $190

□ □ □

HFR1

HFR4 HFR2 HFR3

$55 NC NC $404 $65 $35

□ □ □ □ □ □

HFR5

$375

□

HFP1 HFP2

HFP3 HFP4 HFP5

NC $138 $190 NC $76 $36 $58

□ □ □ □ □ □ □

WAMV

WAMK

WAMJ

HELIO_CANADA‐BC_V0.09aEN

519, J‐Oswald Forest, suite 101 Saint‐Roch‐de‐l'Achigan, QC, Canada J0K 3H0 T.450 588‐6555 1 866 650‐6555 F.450 588‐0200 www.motioncomposites.com

Description CASTERS 53 Composite wheel 54 /w PU tire (1’’ width) 55

3” □ 4” □ 5” □ 6“ □ 7” □ 8” □ 4” x 1 ½” 5” x 1 ½” 6” x 1 ½” 6” x 1 ¼” □ 8” x 1 ¼” □

Composite wheel 1 Soft‐Roll® by Frog Legs

56 57

May 1st, 2011

Pneumatic CASTER OPTIONS 59 Caster pin locks (Available with +1” or +2” Stem bolt only) 60 Frog Legs suspension forks (Not available with caster pin locks) 1 Soft‐Roll® by Frog Legs are casters that absorb vibrations FRONT SEAT‐TO‐FLOOR HEIGHT MATRIX 58

WAMS

HCA1

HCA2 HCA3 HCA4 HCA5

$50 NC $85 $95 $105 $120

□ □ □ □ □ □

HCA6 HCA7

$220 $475

□ □

Circle the desired configuration

Forks 3” 4” 5”

7”

3” caster

4” caster

5” caster

6” caster

7” caster

8” caster

Stem bolt length STD +1” +2”

Stem bolt length STD +1” +2”

Stem bolt length STD +1” +2”

Stem bolt length STD +1” +2”

Stem bolt length STD +1” +2”

Stem bolt length STD +1” +2”

P1

13 ½

14 ½

15 ½

P1 P2 P1 P2 P3 P4 P1 P2 P3 P4 P5

14 14 ½

14 ¾ 15 ¼ 15 ¾

17 ¾

15 15 ½

15 ¾ 16 ¼ 16 ¾

18 ¾

16 16 ½

16 ¾ 17 ¼ 17 ¾

19 ¾

14 ½ 15

15 ¼ 15 ¾ 16 ¼

17 ¾ 18 ¼

15 ½ 16

16 ¼ 16 ¾ 17 ¼

18 ¾ 19 ¼

16 ½ 17

17 ¼ 17 ¾ 18 ¼

19 ¾ 20 ¼

15 ½

16 ½

17 ½

15 ¾ 16 ¼ 16 ¾

16 ¾ 17 ¼ 17 ¾

17 ¾ 18 ¼ 18 ¾

17 ¼ 17 ¾ 18 ¼ 18 ¾

18 ¼ 18 ¾ 19 ¼ 19 ¾

19 ½ 19 ¾ 20 ¼ 20 ¾

16 ¾ 17 ¼ 17 ¼ 17 ¾ 18 ¼ 18 ¾ 19 ¼

17 ¾ 18 ¼ 18 ¼ 18 ¾ 19 ¼ 19 ¾ 20 ¼

REAR WHEELS 61 Mag (Soft urethane tires and plastic coated handrim only) 22” □ 24” □ 62 Spoke 22” □ 24” □ 63 Spinergy Wire® 20” □ 22” □ 24” □ 26” □ 64 Spinergy Spox® 22” □ 24” □ 25” □ 26” □ 65 Spinergy LX® 22” □ 24” □ 25” □ 26” □ TIRES 66 Soft urethane 1 ⅜” 20” □ 22” □ 24” □ 67 Pneumatic 1 ⅜” 20” □ 22” □ 24” □ 25” □ 26” □ 68 Pyramid – hard urethane 1” 22” □ 24” □ 69 Kenda – Ironcap high pressure 1” 20” □ 22” □ 24” □ 25” □ 26” □ 70 Kenda – Kourier high pressure 1 ⅜” 20” □ 22” □ 24” □ 25” □ 26” □ 71 Soft urethane – high performance 1” 22” □ 24” □ 25” □ 26” □

REAR SEAT‐TO‐FLOOR HEIGHT

18 ¾ 19 ¼ 19 ¼ 19 ¾ 20 ¼ 20 ¾ 21 ¼

17 ¾ 17 ¾ 18 ¼ 18 ¾ 19 ¼ 19 ¾

18 ¾ 18 ¾ 19 ¼ 19 ¾ 20 ¼ 20 ¾

19 ¾ 19 ¾ 20 ¼ 20 ¾ 21 ¼ 21 ¾

18 ¾ 19 ¼ 19 ¾ 20 ¼

19 ¾ 20 ¼ 20 ¾ 21 ¼

20 ¾ 21 ¼ 21 ¾ 22 ¼

HRW1

HRW2 HRW3 HRW4

$125 NC $275 $800 $900

□ □ □ □ □

HRT1 HRT2 HTR4 HRT3

NC NC $70 $80 $80 $120

□ □ □ □ □ □

Wheel size 20” wheel 22” wheel 24” wheel 25” wheel 26” wheel

Height available ± ¼” 12 ½” to 17” 13 ½” to 18” 14 ½” to 19” 15” to 19 ½” 15 ½” to 20”

Page 3 of 5

Specify desired height: __________

HELIO_CANADA‐BC_V0.09aEN

519, J‐Oswald Forest, suite 101 Saint‐Roch‐de‐l'Achigan, QC, Canada J0K 3H0 T.450 588‐6555 1 866 650‐6555 F.450 588‐0200 www.motioncomposites.com

May 1st, 2011

Description HANDRIM 72 Aluminum anodized Assembly 73 regular □ narrow □ Plastic coated 74 High friction plastic coated foam 75 Natural Fit – Standard grip (Available with 22” and 24” Spinergy wheels only) 76 Spinergy Flexrim (Available with Spinergy LX 24” only) 77 Omit handrim

WAMO WAMO

HHR1 HHR2 HHR3 HHR4

□ □ □ □ □ □

NC $130 $200 $320 $550 NC

AXLE 78 79 80

Quick release axle Permanent axle Quad release axle AMPUTEE ADJUSTABLE AXLE PLATE (May interfere with Swing away or Flip back armrest)

WAMU

HAX1

NC NC $150

□ □ □

WAMT

HAX2

$165

□

HCB1

NC NC $120

□ □ □

HWL1 HWL2 HWL3

NC $32 $120 $312

□ □ □ □

HPB1 HPB2 HPB3

$32 $40 $16

□ □ □

HAC1 HAC2 HAC3 HAC4 HAC5 HAC6

$75 $85 $124 $50 $75 $25

□ □ □ □ □ □

WAMU

81

REAR WHEEL CAMBER ANGLE 82 0° camber 83 3° camber 84 6° camber (Not available with amputee axle plate)

WHEEL LOCK 85 Push to lock □ Pull to lock □ 86 6” removable extension handle 87 Grade aid push to lock (Suggested with pneumatic or high pressure tire) 88 Scissor brake

WAMR

POSITIONING BELT 89 Velcro adjustable 90 Auto buckle 91 Hardware for 4 points seatbelts

ACCESSORIES 92 Anti tippers 93 Cane Carrier left □ right □ 94 Spoke guards 95 Footrest neoprene impact guard 96 Seat pouch 97 helio T‐Shirt Small □ Medium □ Large □ X‐Large □ XX‐Large □

WAMP

Transit securement points come standard on every Helio wheelchair

Total

Comments :

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HELIO_CANADA‐BC_V0.09aEN

519, J‐Oswald Forest, suite 101 Saint‐Roch‐de‐l'Achigan, QC, Canada J0K 3H0 T.450 588‐6555 1 866 650‐6555 F.450 588‐0200 www.motioncomposites.com

May 1st, 2011

CENTER OF GRAVITY

Check the desired rear wheel position OR Specify the distance: ______ (Measure from front of back post to the center of axle) AMPUTEE PLATE

FRAME SIZE AVAILABLE

BACK CANE HEIGHT 3” of height adjustment

Extended Frame recommendation  Allows for future growth  Increased stability  Use with seat depth < 17” to permit forward center of gravity adjustment



Back upholstery height 

The slip‐on or adjustable tension back upholstery is attached to the push handle offering 3” of height adjustment with increments of ½” Rigid backs are attached to the back cane and the height of the push handle is adjusted independently.

Regular Frame

Extended Frame +1”

Extended Frame +2”

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HELIO_CANADA‐BC_V0.09aEN