Order Form – Nova® Order numer: 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 CityVenezuelaVietnamYemenZambiaZimbabweCountryPhone:(1) Area Code - Phone Number Ship product:*AssembledDissasembledProduct size:*size 1 Turquoise/AQUAsize 2 Black/ MELANGEsize 3 Black/ CADETStandard EquipmentFoldable frameRemovable inflatable wheelsAdjustable wheelbase SmarTractionAdjustable footrest with 2-point feet stabilizing beltsSeat cushionPush handle5-point safety beltsAdjustable headrestSafety railCentral brakeTilt in-space adjustmentAccessories:Safety:NVA/NVE/NVH_001 LED lightsNVA/NVE/NVH_002 Belt for moving patients AM-PPositioning:NVA/NVE/NVH_101 Thigh abduction beltsNVA/NVE/NVH_107 Pelvic brace with pelvic belt (adjustable) NVA/NVE/NVH_114 H-Harness ('hold & pull' system) (Instead) NVA/NVE/NVH_114 H-Harness ('hold & pull' system) (Additionally)NVA/NVE/NVH_126 Trunk beltNVA/NVE/NVH_128 Adjustable abduction blockNVA/NVE/NVH_130 4-point safety vest (Instead) NVA/NVE/NVH_130 4-point safety vest (Additionally)NVA/NVE/NVH_134 Narrowing pads 6 cmNVA/NVE/NVH_137 Narrowing pads 10 cmNVA/NVE/NVH_147 5-point feet stabilizing belts (Instead) NVA/NVE/NVH_161/1 Foot and ankle stabilizing sandals(EUR: 21 – 24, CM: 13 – 15 cm; UK: 4,5 – 7, IN: 5,1 – 5,9 in)NVA/NVE/NVH_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)NVA/NVE/NVH_161/3 Foot and ankle stabilizing sandals(EUR: 27 – 31, CM: 17 – 19,5 cm; UK: 9 – 12, IN: 6,7 – 7,7 in)NVA/NVE/NVH_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)NVA/NVE/NVH_162/1 Dynamic ankle stabilizers (FP-22)(size XS, perimeter of the ankle CM: 4 – 17 cm; IN: 6-7 in)NVA/NVE/NVH_162/2 Dynamic ankle stabilizers (FP-22)(size S, perimeter of the ankle CM: 16.5 – 20 cm; IN: 6-8 in)NVA/NVE/NVH_162/3 Dynamic ankle stabilizers (FP-22)(size M, perimeter of the ankle CM: 19 cm – 23.5 cm; IN: 7-9 in)NVA/NVE/NVH_162/4 Dynamic ankle stabilizers (FP-22)(size L, perimeter of the ankle CM: 23 cm – 28 cm; IN: 9-11 in)NVA/NVE/NVH_162/5 Dynamic ankle stabilizers (FP-22) (size XL, perimeter of the ankle CM: 26.5 cm – 33 cm; IN: 10-13 in)NVA/NVE/NVH_163 Anatomic thigh abduction belts (FP-23)Comfort:NVA/NVE/NVH_403 TrayNVA/NVE/NVH_405 Folding canopyNVA/NVE/NVH_408 Rain cover (Only with NVA/NVE/NVH_405)NVA/NVE/NVH_411 Cup holderNVA/NVE/NVH_412 Elastico seat cushionNVA/NVE/NVH_415 Rear wheel covers (Indicate how many pc. you need in "message to us" below)NVA/NVE/NVH_429 Soft footrest coverNVA/NVE/NVH_445 FootmuffNVA/NVE/NVH_447 Winter muffsNVA/NVE/NVH_448/1 Self-leveling tray size 1NVA/NVE/NVH_448/2 Self-leveling tray size 2NVA/NVE/NVH_448/3 Self-leveling tray size 3NVA/NVE/NVH_448/4 Self-leveling tray size 4NVA/NVE/NVH_448/5 Self-leveling tray size 5NVA/NVE/NVH_452 Phone holderNVA/NVE/NVH_453 Seat cushion with bolsterNVA/NVE/NVH_454 Cut-out seat cushion with bolsterStorage:NVA/NVE/NVH_501 BagNVA/NVE/NVH_506 Carrier bag with pockets for wheelsNVA/NVE/NVH_509 Organizer bagBuild-up:NVA/NVE _625 HOME moduleNVA/NVH_626 EVO moduleNVA/NVH_630 Bicycle tow bar with a flagSpare parts:NVA/NVE/NVH_700 Waterproof upholstery HYDRO™NVA/NVE_701 Rear infltable wheel (Indicate how many pc. you need in "message to us" below)NVA/NVE_704 Rear PU wheel (Instead) (Indicate how many pc. you need in "message to us")NVA/NVE_704 Real PU wheel (Additionally) (Indicate how many pc. you need in "message to us")NVA/NVE/NVH_722 Flex upholstery (Additionally)NVA/NVE/NVH_770 Upholstery - set (Additionally)NVA/NVE/NVH_773 Bag with granulesMessage to us:SubmitReset