Order form – Ulises 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 1size 1asize 2size 2asize 3Rim colour*GrayBlackChoose upholstery:Upholstery colours:*Green GrassHot RedBlue SeaBlue WaveGrey VulcanoStandard equipmentFlex upholstery5 points safety beltAdjustable footrest with 2 points feet stabilizing beltsWheels with glass fiber, rear inflatable with 2 separate wheel locksFront PU swivel Angle adjustable backrestAdjustable push handlesBodyPrint™ seat Belt system adjusting the tension of the seat upholstery and backrestAdjustable height and tilt angle of the footrestAdjustable depth of the seatBackrest extensionHeadrest Accessories:Safety:ULE_001 LED lights ULE_002 Belt for moving the patients AM-PULE_013 Safety rail ULE_021 Knee protectorsPositioning:ULE_101 Thigh abduction beltsULE_107 Pelvic belt (adjustable)ULE_113 Trunk stabilizing belt (W)ULE_114 H Harness ('hold & pull' system) (instead)ULE_114 H Harness ('hold & pull' system) (additional)ULE_115 Calf belt (W)ULE_124 Loins support (W)ULE_125 6 points harness (instead)ULE_125 6 points harness (additional)ULE_126 Trunk beltULE_128 Abduction blockULE_129 Abduction-adduction thigh belts ULE_130 4 points safety vest (additional)ULE_130 4 points safety vest (instead)ULE_132 Elastico headrestULE_133 Firm foam headrestULE_134 Narrowing pads 6 cm ULE_136 Thigh beltsULE_137 Narrowing pads 10 cm ULE_147 5 points feet stabilizing belts (instead)ULE_148 High lateral supportsULE_149 Rigid pelvic supports with narrowing pads 6 cmULE_150 Rigid pelvic supports with narrowing pads 10 cmULE_153 Low lateral supportsULE_160 Octagon™ headrest (size 1)ULE_160 Octagon™ headrest (size 2)ULE_160 Octagon™ headrest (size 3)ULE_161/1 Foot and ankle stabilizing sandals(EUR: 21 – 24, CM: 13 – 15 cm; UK: 4,5 – 7, IN: 5,1 – 5,9 in)ULE_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)ULE_161/3 Foot and ankle stabilizing sandals(EUR: 27 – 31, CM: 17 – 19,5 cm; UK: 9 – 12, IN: 6,7 – 7,7 in)ULE_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)ULE_162/1 Dynamic ankle stabilizers (FP-22)(size XS, perimeter of the ankle CM: 4 – 17 cm; IN: 6-7 in)ULE_162/2 Dynamic ankle stabilizers (FP-22)(size S, perimeter of the ankle CM: 16.5 – 20 cm; IN: 6-8 in)ULE_162/3 Dynamic ankle stabilizers (FP-22)(size M, perimeter of the ankle CM: 19 cm – 23.5 cm; IN: 7-9 in)ULE_162/4 Dynamic ankle stabilizers (FP-22)(size L, perimeter of the ankle CM: 23 cm – 28 cm; IN: 9-11 in)ULE_162/5 Dynamic ankle stabilizers (FP-22)(size XL, perimeter of the ankle CM: 26.5 cm – 33 cm; IN: 10-13 in)ULE_163 Anatomic thigh abduction belts (FP-23)Comfort:ULE_402 UmbrellaULE_403 Tray (black color) ULE_403 Tray (light grey)ULE_405 Folding canopyULE_408 Rain coverULE_409 Mosquito net (W)ULE_410 Headrest cotton cover (W)ULE_411 Cup holderULE_412 Elastico seat cushion (W)ULE_415 Rear wheel coversULE_416 Summer footmuff (W)ULE_417 Winter footmuffULE_418 Hood for winter footmuff (W)ULE_419 Shaped seat cushion (thigh shape) (W)ULE_421 Seat cushion (pommel shape) (W)ULE_429 Sof footrest coverULE_433 Lifting barULE_437 Extended foot rest (size 1 - 6cm; size 1a,2 - 8 cm; size 2a, 3 - 10 cm) with front wheels swivel lock (additionally)ULE_437 Extended foot rest (size 1 - 6cm; size 1a,2 - 8 cm; size 2a, 3 - 10 cm) with front wheels swivel lock (instead)ULE_439 HandbrakeULE_440 Front wheel locksULE_442 Front wheel coversULE_444 ArmrestsULE_447 Winter muffsULE_448/1 Self-leveling tray size 1ULE_448/2 Self-leveling tray size 2ULE_448/3 Self-leveling tray size 3ULE_448/4 Self-leveling tray size 4ULE_448/5 Self-leveling tray size 5ULE_452 Phone holderStorage:ULE_505 Under seat storage basketULE_506 Carrier bag for the strollerULE_507 Oxygen tank holder ULE_509 Organizer bagSpare parts:ULE_701 Rear inflatable wheelULE_704 Rear PU wheel (additional)ULE_704 Rear PU wheel (instead)ULE_707 Front infatable wheel (additional)ULE_707 Front infatable wheel (instead)ULE_711 Front PU wheel ULE_723 Upholstery comfortULE_773 Bag with granulesAttention, some accessories mutually exclusive each other. Please refer to the table belowMessage to us:SubmitReset