Order form – Dalmatian Invento Order number: Order Date:Company name / Name and surname Bill adress:* Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryE-mail:*Phone* Area Code - Phone Number Click if:shipping adress is the same as bill adressShip to: Shipment adress: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryContact: Area Code - Phone Number Ship product:*AssembledDissasembledProduct size*size 1size 2size 3Choose upholstery:Upholstery colours:*GrassSeaLatteRedGreen GrassBlue SeaBrown SugarHot RedCitrus greenCandyPillarboxStandard EquipmentFrame with castors equipped with brakesPneumatic springDeep adjustable seatRemovable and adjustable abduction blockKnee supportBackrestHold&pull pelvic beltChest suport (size 1, 2)Independently adjustable pelvic and chest support (size 3)Hold&pull vestHead-restForearm supportsTrayIndependently adjustable footrestInnovative quadric mechanismAccessories:Safety:DMI_002 Belt for moving the patients AM-PDMI_003 Soft cover for tray (W)DMI_015 TANGO Wheel (75 mm) (additional)DMI_015 TANGO Wheel (75 mm) (instead)DMI_016 TANGO Wheel (125 mm) (additional)DMI_016 TANGO Wheel (125 mm) (instead)DMI_020 TANGO Wheel (100 mm) (additional)DMI_020 TANGO Wheel (100 mm) (instead)DMI_023 TANGO Wheel with fixed direction of movement (75 mm)Positioning:DMI_101 Thigh abduction beltsDMI_102 Head supporting beltDMI_103 3D foot adjustment (U) (instead)DMI_106 Lower limbs supporting cushionsDMI_109 Independently adjustable side supports (instead)DMI_114 H Harness ('hold & pull' system) (additional)DMI_114 H Harness ('hold & pull' system) (instead)DMI_123 Adjustable extended headrest (instead)DMI_125 6 points safety vest (additional)DMI_125 6 points safety vest (instead)DMI_126 Trunk beltBodymap Positioning:DMI_340 HexagonPro™ BodyMap® Headrest DZ - size 1DMI_340 HexagonPro™ BodyMap® Headrest DZ - size 2DMI_340 HexagonPro™ BodyMap® Headrest DZ - size 3Comfort:DMI_401 Tray for manual therapy (W)DMI_407 Tray for nonverbal communication (W)DMI_410 Headrest cotton cover (W)DMI_412 Elastico cushion seat (A) (W)DMI_423 Castor with brakeDMI_431/1 Push handle, height - 1 cm from the backrest DMI_431/2 Push handle, height - 19 cm from the backrest DMI_431/3 Push handle, height - 31 cm from the backrest Storage:DMI_507 Oxygen tank holder Spare parts:DMI_700 Waterproof upholstery HYDRO™ (instead)DMI_720 Breathable upholstery ATMO™ (instead)DMI_725 Medical upholstery MEDICUS™ (instead)DMI_726 Standard feet sandal DMI_727 Chest supportsDMI_728 4 points safety vestDMI_733 Seat cushionDMI_735 Adjustable HexagonPro© HeadrestDMI_739 Medical upholstery EXTREME-MED ™ (instead)DMI_740 Removable and adjustable abduction blockDMI_744 TrayDMI_747 Pelvic beltDMI_751 Backrest cushionDMI_754 Forearm supportDMI_755 Gas springDMI_757 Knee supportMessage to us:SubmitReset
