Order form – Dominator Evo 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 2size 3Standard equipmentFoldable frameAdjustable push handleHand brakeAdjustable chest supportsSide tubes protectorsAdjustable armrestsAdjustable head supportsBackrest with heigh and tilt angle adjustmentChest beltAdjustable pelvic supportsAbduction blockSeat cushionSide covers for calveskFootrest with 5-point feet stabilizing beltsTilt-in-space adjustmentInflatable rear wheels with drum brakeFront swivel wheels with direction blockade NEW: VOYAGER backpack.SAFETY:DTE_001 LED lightsDTE_002 Belt for moving patients AM-PDTE_003 Soft cover for trayPOSITIONING:DTE_101 Tigh abduction beltsDTE_121 Head-neck supportDTE_161/1 Foot and ankle stabilizing sandals (EUR: 21 – 24, CM: 13 – 15 cm; UK: 4,5 – 7, IN: 5,1 – 5,9 in)DTE_161/2 Foot and ankle stabilizing sandals (EUR: 25 – 27, CM: 15 – 17 cm; UK: 7,5 – 9,5, IN: 5,9 – 6,7 in)DTE_161/3 Foot and ankle stabilizing sandals (EUR: 27 – 31, CM: 17 – 19,5 cm; UK: 9 – 12, IN: 6,7 – 7,7 in)DTE_161/4 Foot and ankle stabilizing sandals (EUR: 31 – 35, CM: 19,5 – 22,4 cm; UK: 12 – 2,5, IN: 6,7 – 8,8 in)DTE_162/1 Dynamic ankle stabilizers (FP-22) (size XS, perimeter of the ankle CM: 4 – 17 cm; IN: 6 – 7 in)DTE_162/2 Dynamic ankle stabilizers (FP-22) (size S, perimeter of the ankle CM: 16,5 – 20 cm; IN: 6 – 8 in)DTE_162/3 Dynamic ankle stabilizers (FP-22) (size M, perimeter of the ankle CM: 19 cm – 23,5 cm; IN: 7 – 9 in)DTE_162/4 Dynamic ankle stabilizers (FP-22) (size L, perimeter of the ankle CM: 23 cm – 28 cm; IN: 9 – 11 in)DTE_162/5 Dynamic ankle stabilizers (FP-22) (size XL, perimeter of the ankle CM: 26,5 cm – 33 cm; IN: 10 – 13 in)DTE_170/2 Pelvis stabilizer (FP-16) (size M, pelvic width 25 - 31 cm, depth 21 cm, height 23 cm) (1) (size 2)DTE_170/3 Pelvis stabilizer (FP-16) (size L, pelvic width 31 - 38 cm, depth 24 cm, height 25 cm) (1) (size 2, 3)DTE_170/4 Pelvis stabilizer (FP-16) (size XL, pelvic width 38 - 45 cm, depth 30 cm, height 27 cm) (1) (size 3)COMFORT:DTE_402 UmbrellaDTE_403 TrayDTE_405 Folding canopy*DTE_408 Rain cover *DTE_409 Mosquito netDTE_411 Cup holderDTE_415 Rear wheel coversDTE_417 Winter footmuff with muffsDTE_442 Front wheel covers DTE_447 Winter muffsDTE_452 Phone holderDTE_453 Seat cushion with bolster **STORAGE:DTE_501 BagDTE_506 Carrier bag for the strollerDTE_509 Organizer bagDTE_512 FLASH backpack* ONLY WITH FOLDING CANOPY (DTE_405). ** IT IS NOT POSSIBLE TO USE THE ABDUCTION BLOCK WHILE USING THE SEAT CUSHION WITH BOLSTER. (1) SUGGESTED SIZES. MORE DETAILS ON WWW.FLEX-POINT.PL/ENMessage to us:SubmitReset
