Order form – Jumbo™ 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 3Standard EquipmentFrame with castors and brakesAdjustable, folding footrest with feet stabilizing beltsSeatAdjustment backrestPelvic beltMedical upholstery MEDICUS™: MED SEAAccessories:Positioning:SLK_101 Thigh abduction beltsSLK_102 Head supporting belt for HexagonPro™ Headrest SLK_102 Head supporting belt for VisoPro™ Headrest SLK_104 HexagonPro™ HeadrestSLK_114 H Harness (I) (1) SLK_114 H Harness (A) (1) SLK_123 Adjustable extended headrest SLK_124 Loins support SLK_125 6 points safety vest S (I) (1) SLK_125 6 points safety vest S (A) (1) SLK_125 6 points safety vest M (I) (1) SLK_125 6 points safety vest M (A) (1) SLK_125 6 points safety vest L (I) (1) SLK_125 6 points safety vest L (A) (1) SLK_125 6 points safety vest XL (I) (1) SLK_125 6 points safety vest XL (A) (1) SLK_128 Abduction block (2) SLK_130 4 points safety vest (I) (1)SLK_130 4 points safety vest (A) (1)SLK_154 Knee abductor (2) SLK_155 Chest supportsSLK_155 Pelvic supportsSLK_161/1 Foot and ankle stabilizing sandals (EUR: 21 – 24, CM: 13 – 15 cm; UK: 4,5 – 7, IN: 5,1 – 5,9 in)SLK_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)SLK_161/3 Foot and ankle stabilizing sandals (EUR: 27 – 31, CM: 17 – 19,5 cm; UK: 9 – 12, IN: 6,7 – 7,7 in)SLK_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)SLK_162/1 Dynamic ankle stabilizers (FP-22) (size XS, perimeter of the ankle CM: 4 – 17 cm; IN: 6 – 7 in)SLK_162/2 Dynamic ankle stabilizers (FP-22) (size S, perimeter of the ankle CM: 16,5 – 20 cm; IN: 6 – 8 in)SLK_162/3 Dynamic ankle stabilizers (FP-22) (size M, perimeter of the ankle CM: 19 cm – 23,5 cm; IN: 7 – 9 in)SLK_162/4 Dynamic ankle stabilizers (FP-22) (size L, perimeter of the ankle CM: 23 cm – 28 cm; IN: 9 – 11 in)SLK_162/5 Dynamic ankle stabilizers (FP-22) (size XL, perimeter of the ankle CM: 26,5 cm – 33 cm; IN: 10 – 13 in)SLK_168 VisoPro™ Headrest Comfort:SLK_403 Tray*SLK_453 PA-VM-15 Cushion (Seat cushion with bolster) Storage:SLK_507 Oxygen tank holder * IT IS NOT POSSIBLE TO USE THE ADJUSTABLE ABDUCTION BLOCK WHILE USING THE SEAT CUSHION WITH BOLSTER.** CUSTOM-MADE. LEAD TIME ca. 30 DAYS(I) INSTEAD OF PELVIC BELT.(1) H HARNESS, 4 POINTS AND 6 POINTS SAFETY VESTS SHOULD BE USED WITH ELEMENTS SLK_128, SLK_154 OR SLK_101.(2) ELEMENTS SLK_128 AND SLK_154 CANNOT BE USED TOGETHERMessage to us:SubmitReset