Custom Seating System Order FormPlease complete the following:

web: www.RichardsonProducts.com

email: RPI@RichardsonProducts.com

phone: (888) 928-7297

fax: (815) 464-3576

Company :

Patient Name :

Phone :

P.O. Number :

Notes :

Solid I-ModificationT-Modification

Bi-Angular 3-Plane Contoured

Solid T-Modification I-Modification

Anti-Thrust Contoured

A

Q

P

S

O

R

N

E FD

CB SeatsBacks

Email :

Ordered By :

Adj. Lumbar

Curved

Options*Solid, T-Mod, & I-Mod only

Please select a Back/Seat and fill in all appropriate dimensions.

2 Right

1

HCPC E2609

HCPC E2617

Left

3 Right

Left

5 Right

Left

4

6

Patient Measurements

Chair Construction

Rail Width : Seat Depth :

Full Width

Between Rails

Seat Style:Back Style:Full Width

Between Rails

Standard Backs/Seats:

Measurements

SS-04.1

*Please see next page for standard materials and configurations. * Please see next page to specify any alterations .

Custom Seating System Order Form (page 2)

Please complete the following:

web: www.RichardsonProducts.com

email: RPI@RichardsonProducts.com

phone: (888) 928-7297

fax: (815) 464-3576Patient Name :

P.O. Number :

Notes :

Mounting Hardware

Cover Alterations

0"

Foam Alterations

Basic Alterations

Frame Notches (std = 1"x1")

Fixed Drop:

- ½" Wood Base - 1½" HR Foam - 2 Rows of T-nuts - Black Vinyl Cover

Standard Back/Seat

Back Seat

3rd Row of T-nuts

Embroidery

Additional HR foam

Back Seat

Memory Foam, med-soft

Visco, yellow

Visco, green

Visco, blue

Visco, pink

Ethafoam

Dartex (cloth)

Back Seat

Neoprene

Vinyl

Adjustable:

Fixed Lift:

90º- 8 hole

90º- 4 hole90º- 6 hole

90º- 2 hole

J Hook- 8 holeJ Hook- 6 holeJ Hook- 4 holeJ Hook- 2 hole

1½"1"½"

3"2"1½"1"

Back Seat

Back Seat

Back Seat

HCPC K0108

Alterations

SS-04.2

**This drawing shows the Standard Configurations for all backs or seats made by Richardson Products. To alter any of these measurements, please use the drawing to mark your own appropriate dimensions.

- Standard 45º angle foam taper on Anti-Thrust and Contoured Seats

- Standard 8º angle between planes on Bi-Angular and 3-Plane Backs

Dartex (rubber)

Custom Seating System Order Form (page 3)

Please complete the following:

web: www.RichardsonProducts.com

email: RPI@RichardsonProducts.com

phone: (888) 928-7297

fax: (815) 464-3576Patient Name :

P.O. Number :

soft curved- small

Headrest Pads (page 16)

soft curved- large

molded- small

molded- large

headrest hardware

male

Chest Harnesses (page 22)

female

small

medium

large

fixed strap

adjustable strap

non-padded, 2 point

Positioning Belts (pages 23-24)

padded, 2 point

2" webbing

1½" webbing

1" webbingpadded, 4 point

small

Torso Pads (page 17)

medium large

fixed

Lateral Brackets (pages 28-29)

swing-away

12"

Hip Pads (page 18)

14" 16" 18"8" 10" 20"wood

small

Abductors (page 18)

medium large

small

Ankle Positioners (page 24)

medium

large

Shoe Holders (page 19)

small medium large

one piece

Foot Boxes (page 19)

two piece

small

medium

large

x-large

⅜" polycarbonate

Trays (pages 4-5)

¼" polycarbonate

child

junior

teen

adult

x-wide

2x-wide

E0957

HCPC

E0957 +E1028

E0951 +E0952

E0951 +E0952

E0955

E1028

E0960

E1028

E0950

E0956K0108

E0978

HCPC

Accessories

SS-04.3

soft curved- x-large

26"

Transfer Boards (page 20)

29" 35"

E0705

buckle

Ankle Straps (page 24)

camlock

d-ring

E0038

2" webbing

1" webbing

buckle

d-ring

5" x 7"

Stump Supports (page 18)

7" x 10"

E0959

4" x 12"

Chest Straps (page 23)

4" x 15"

E0960

6" x 12" 6" x 15"