PO#:
Dealer Name:
Address:
Phone#:
Contact:
Dealer Code:
City:
Fax#:
First Name:
Last Name:
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:
Please send order/quote to fax#: (800) 231-3256 Effective October 9th 2003 All specifications and prices are subject to change without notice.
Permobil Inc.
6961 Eastgate Blvd.
Lebanon, TN 37090 Tel: (800) 736-0925 Fax: (800) 231-3256 www.permobil.com State/Zip:
Diagnosis:
Permobil recommends that the client is evaluated by a certified rehab specialist.
Required information for chair to be properly adjusted to client's measurements.
Dealer Information
Client Information
Client Measurements
Chairman Entra Stander JR
Base
Select Options:
Part Number Description Retail Price:
$5,995.00 Entra Stander Junior Base
I101890-99-0
Price Includes : Entra FWD Power Base Configured for the Standing Seat, Programmable Pilot + Controller, Remote Joystick, Swing-Away Joystick Hardware, Tie-down Hardware for Strap Systems, Charger, Freight and Anti-tippers. Weight Limit 155lbs.
Select one of the following:
Part Number Description Retail Price:
No Charge Entra Base Cover Silver/Black
I100853-99-0
No Charge Entra Base Cover Black
I100842-99-0
No Charge Entra Base Cover Blue
I100845-99-0
No Charge Entra Base Cover Red
I100843-99-0
No Charge Entra Base Cover Silver
I100844-99-0
Base Options
Select Options:
Part Number Description Retail Price:
$675.00 Batteries, Group 24 Sealed LA/Gel, Installed
IM24 SLD G FT
No Charge High Ground Clearance Package
I10118
Provides greater ground clearance and assists in the mounting of power lock-down transportation systems.
$2,130.00 Power Adjustable Seat Height, 8" Travel
I100558-99-0
To assist in transfers.
No Charge Seat Tube Fixed
I100499-99-0
$887.00 Light Kit Entra
I100851-99-0
$457.00 P+ PP1A Programmer
I602307-99-0
Joystick Options
Select one of the following:
Part Number Description Retail Price:
Cone shaped joystick knob is standard.
$73.00 Chin Cup For Joystick Knob
I100960-99-0
$107.00
"T" Handle For Joystick Knob I100961-99-0
$73.00
"Large Ball" For Joystick Knob I100962-99-0
$97.00
"Softball" For Joystick Knob I100963-99-0
$97.00
"Mushroom" For Joystick Knob I100964-99-0
$97.00
"Stick" For Joystick Knob I100965-99-0
Select Options:
Part Number Description Retail Price:
No Charge Joystick Mount-Right
I100398-99-0
No Charge Joystick Mount-Left
I100399-99-0
$426.00 Retractable joystick Mnt Right
I100819-99-0
$426.00 Retractable joystick Mnt Left
I100824-99-0
$231.00 Midline Control Mount
I101260-99-0
No Charge Pilot+ series Joystick w/ 7 Buttons
ID49670/3
$165.00 Pilot+Series joystick T/S
ID50002
Toggle switches for power and mode.
$165.00 Pilot+ Joystick M/J
ID49880
1/8" Mini-mono jack switch ports for power and mode. (Switches not included)
Joystick Options
Select Options:
Part Number Description Retail Price:
$995.00 P+DAC Attendant Control
ID49682
For additional joystick options see the Alternative Drive Systems order form.
Seating System
Select one of the following:
Part Number Description Retail Price:
Price Includes:
Standing Seat Frame with Adjustable Seat Depth, Power Standing Feature, Fixed Chest Bar, Solid Seat Pan, Knee Block Assembly, Seat Control Panel with Toggle Switches, and Positioning Belt. Weight Limit 155lbs.
$13,395.00 Combination Standing Seat Junior
I101438-99-0
Includes 16 degrees power tilt and 175 degree power recline
Seating System Options
Select Options:
Part Number Description Retail Price:
No Charge Seat Function Control Kit Toggle Switch Box
I101430-99-0
$816.00 Seat Control Joyswitch
IJOYSWITCH
Multi directional toggle to operate up to 4 power seat functions. Provides an alternative to the membrane switch box and accessing seat functions through the drive control.
$816.00 Alternating Seat Control
IALTSWITCH
Seat function interface box which accommodates 4 single momentary switches. 1/8" mini-mono switches not included. Provides an alternative to the membrane switch box and accessing seat functions through the drive control.
Backrest Options
Select one of the following:
Part Number Description Retail Price:
Backrest height measured from seat pan
$828.00 Ergo Backrest 14" Wide Leatherette 25.5" High
I100794-99-0
$854.00 Ergo Backrest 14" Wide Fabric 25.5" High
I100791-99-0
$557.00 Ergo Backrest 16" Wide Leatherette 25.5" High
I100795-99-0
$583.00 Ergo Backrest 16" Wide Fabric 25.5" High
I100792-99-0
$759.00 Ergo Backrest 18" Wide Leatherette 25.5" High
I100796-99-0
$785.00 Ergo Backrest 18" Wide Fabric 25.5" High
I100793-99-0
No Charge Omit Backrest Kit 14" W Between Armrests
I100434-99-0
No Charge Omit Backrest Kit 16" W Between Armrests
I100435-99-0
No Charge Omit Backrest Kit 18" W Between Armrests
I100436-99-0
$982.00 Rectangular Backrest 16 W
I10004
Choose backrest height from seat pan: 17"-29" ___"
$1,147.00 Rectangular Backrest 18 W
I10005
Choose backrest height from seat pan: 17"-29" ___"
$706.00 Ergo Back Fixed Tall 16"W x 29.5"H Leatherette
I305510-00-90-0
$731.00 Ergo Back Fixed Tall 16"W x 29.5"H Fabr
I305510-00-80-0 Select Options:
Part Number Description Retail Price:
Backrest Options
Select Options:
Part Number Description Retail Price:
No Charge 21" Back Height (Ergo Only)
I10047
$546.00 Custom Ergo Back Height ____"
I10014
Backrest height measured from seat pan. Price in addition to above backrest.
$312.00 Split Backrest
I100972-99-0
Split Backrest and cushion 8" from top to allow for transfers and/or transportation. N/A on short back heights. Split cushion? Y or N
$209.00 Backrest Reinforcement
I101101-99-0
Seat Sizing
Select one of the following:
Part Number Description Retail Price:
No Charge Standing Seat 17"W x 14"D NO Cushion
I101036-99-0
No Charge Standing Seat 17"W x 15"D NO Cushion
I101039-99-0
No Charge Standing Seat 17"W x 16"D NO Cushion
I100415-99-0
No Charge Standing Seat 17"W x 17"D NO Cushion
I100418-99-0
No Charge Standing Seat 17"W x 18"D NO Cushion
I100421-99-0 Select Options:
Part Number Description Retail Price:
$304.00 Ergonomic Seat Cushion Leatherette
I10038
$330.00 Ergonomic Seat Cushion Fabric
I10039
Armrest Options
Select one of the following:
Part Number Description Retail Price:
$73.00 Armrest 4"x10" Right Leatherette
I100550-99-0
$83.00 Armrest 4"x10" Right Fabric
I100542-99-0
No Charge Armrest 4"x12" Right Leatherette
I100551-99-0
$10.00 Armrest 4"x12" Right Fabric
I100543-99-0
$73.00 Armrest 4"x14" Right Leatherette
I100552-99-0
$83.00 Armrest 4"x14" Right Fabric
I100544-99-0
$73.00 Armrest 4"x16" Right Leatherette
I100553-99-0
$83.00 Armrest 4"x16" Right Fabric
I100545-99-0
Select one of the following:
Part Number Description Retail Price:
$73.00 Armrest 4"x10" Left Leatherette
I100546-99-0
$83.00 Armrest 4"x10" Left Fabric
I100538-99-0
No Charge Armrest 4"x12" Left Leatherette
I100547-99-0
$10.00 Armrest 4"x12" Left Fabric
I100539-99-0
$73.00 Armrest 4"x14" Left Leatherette
I100548-99-0
$83.00 Armrest 4"x14" Left Fabric
I100540-99-0
$73.00 Armrest 4"x16" Left Leatherette
I100549-99-0
$83.00 Armrest 4"x16" Left Fabric
I100541-99-0 Select Options:
Part Number Description Retail Price:
$249.00 Height Adjustable Armrest Assembly
I10016
This item must be checked if ordering armrests.
Armrest Options
Select Options:
Part Number Description Retail Price:
$180.00 18" Between Armrests w/ 16" Backrest
I304968-99-0
No Charge Armrest Mount High
I101003-99-0
No Charge Armrest Mount Low (High Position Standard)
I101002-99-0
$84.00 Armrest Height Ext (+2")
I100523-99-0
$219.00 Arm Trough Adaptor 1" Pair
IARMADAP1"
For aftermarket arm troughs.
$219.00 Arm Trough Adaptor 7/8" Pair
IARMADAP7/8"
For aftermarket arm troughs.
$141.00 Armrest Pouch-Right
I100671-99-0
$141.00 Armrest Pouch-Left
I100672-99-0
$112.00 Armrest Side Support Right Inner
I101263-99-0
Recommend 2" wider width between the armrest to ensure armrests will flip-up.
$112.00 Armrest Side Support Right Outer
I101261-99-0
$112.00 Armrest Side Support Left Inner
I101264-99-0
Recommend 2" wider width between the armrest to ensure armrests will flip-up.
$112.00 Armrest Side Support Left Outer
I101262-99-0
Legrest Options
Select one of the following:
Part Number Description Retail Price:
No Charge Legrest, Junior-Leatheret (For Stand Only orTilt)
I100815-99-0
$10.00 Legrest, Junior-Fabric (For Stand Only orTilt)
I100814-99-0
No Charge Legrest, Adult-Leatherett (For Stand Only orTilt)
I100817-99-0
$10.00 Legrest, Adult-Fabric (For Stand Only orTilt)
I100816-99-0
No Charge Legrest, Junior-Leath. (For Combi or Recline)
I100821-99-0
$10.00 Legrest, Junior-Fabric (For Combi or Recline)
I100820-99-0
No Charge Legrest, Adult-Leath. (For Combi or Recline)
I100823-99-0
$10.00 Legrest, Adult-Fabric (For Combi or Recline)
I100822-99-0 Select Options:
Part Number Description Retail Price:
No Charge Calf Supports Leatherette
I101045-99-0
$10.00 Calf Supports Fabric
I101044-99-0
Accessories
Select Options:
Part Number Description Retail Price:
$422.00 Headrest-Removable Leatherette-For Ergo Back
I100509-99-0
$448.00 Headrest-Removable Fabric-For Ergo Back
I100508-99-0
$156.00 Universal Headrest Adapter
IHEADADAPTER
$401.00 Lateral Supports Std. Leatherette-ErgoBack Only
I305266-28-90-0
$426.00 Lateral Supports Std. Fabric-Ergo Back Only
I305266-28-80-0
$615.00 Swing Away Trunk Supports Leatherette-For Ergo Back
I100521-99-0
$641.00 Swing Away Trunk Supports Fabric-For Ergo Back
I100520-99-0
No Charge Lateral Wedges, Pair
I306400-00-0
$194.00 Chest Bar 14" Adjustable Leatherette
I101099-99-0
Accessories
Select Options:
Part Number Description Retail Price:
$219.00 Chest Bar 14" Adjustable Fabric
I101098-99-0
$185.00 Chest Bar 16" Adjustable Leatherette
I101095-99-0
$211.00 Chest Bar 16" Adjustable Fabric
I101094-99-0
$204.00 Chest Bar 18" Adjustable Leatherette
I101097-99-0
$230.00 Chest Bar 18" Adjustable Fabric
I101096-99-0
$453.00 Small Thigh Supports Leatherette
I101041-99-0
$479.00 Small Thigh Supports Fabric
I101040-99-0
$435.00 Abductor Kit
I100978-99-0
$369.00 Transfer Handles
I100974-99-0
$297.00 Push Handles
I101100-99-0
$49.00 Back Pack Clips Carabiner Style
I101473-99-0
$32.00 Back Pack Hooks
I100981-99-0
No Charge Positioning Belt
I100518-99-0
$376.00 Upper Extremity Support Small, Angle Adjustable
I100578-99-0
Swing Away Mounting
$426.00 Upper Extremity Support Angle Adjustable. 14" W
I100575-99-0
$436.00 Upper Extremity Support Angle Adjustable. 16" W
I100576-99-0
$459.00 Upper Extremity Support Angle Adjustable. 18" W
I100577-99-0
$474.00 Upper Extremity Support Joystick Cutout 16" W
I100571-99-0
Swing Away Mounting
$474.00 Upper Extremity Support Joystick Cutout 18" W
I100572-99-0
Swing Away Mounting
$549.00 Upper Extremity Support Mid Joystick Cutout 16"W
I100573-99-0
Swing Away Mounting
$549.00 Upper Extremity Support Mid Joystick Cutout 18"W
I100574-99-0
Swing Away Mounting
