Page 1 of 2INFINFB3701/RevE/01OCT2017
Victory® 10 LX - 4 Wheel Scooter, Quick Ship Order Form
Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected]
Account Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
Black Vinyl, High Back, 18"W x 18"D. ..................... StandardWith SlidersPart: SET147133
Black Vinyl, High Back, 22"W x 18"D ............................. $350Without SlidersPart: SET151622
SEATINGREQUIRED. Select one seat.
COLORREQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration used.
Candy Apple RedPart: DGN154334
True BluePart: DGN154333
MODELREQUIRED. 400 lb. weight capacity. More details and specifications at found at pridemobility.com/scooters.
Victory 10 LX with CTS Suspension. ............................................................................................................................................. $2,899Part: S710LX. HCPCS: K0899, Power mobility device, not coded by DME PDAC or does not meets criteria
Includes standard options:• Two 40 Ah AGM batteries• 5-AMP Off-board charger• Light Package• Front Basket• Rear View Mirror
ACCESSORIESOptional.
4-Wheel, Black, Weather Cover ....................................... $202Part: ACCCOVR1018
Saddle Bag (12.5" x 9.875") ................................................ $35Part: DWR1020D010
Safety Flag ............................................................................ $38Part: ACCASMB2079
Cup Holder, Style-B (Used on 22" W Seats)..................... $20Part: ACCASMB2287
Cup Holder, Style-D (Used on 18" W Seats) ..................... $20Part: ACC120041
Rear View Mirror .................................................................. $25Part: LGTRMIR1003
Cell Phone Holder .................................................................$70Part: ACC145549
This form is interactive when viewed in Adobe Acrobat Reader and may not function correctly if opened with applications other than Acrobat. HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for determining the appropriate billing codes when submitting for insurance reimbursement. Payer coding, coverage, and bundling guidelines may apply. All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete scooter. Please contact technical service for accurate parts ordering.
Thank you for choosing Pride Mobility Products!
INTRODUCTION
Air Force Patch ............................... $20Part: ACC140240
Army Patch ..................................... $20Part: ACC140241
Coast Guard Patch ........................ $20Part: ACC140239
Marines Patch ................................. $20Part: ACC140243
Navy Patch ...................................... $20Part: ACC140244
Purple Heart Patch ........................ $20Part: ACC140238
Page 2 of 2INFINFB3701/RevE/01OCT2017
Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected]
Mobility Made Easy. Pride offers a variety of lifts to transport your mobility product with ease. To find a compatible lift for your vehicle and mobility product, use our new Lift Finder applica-tion at pridemobility.com/lift-finder
Account Number: ___________ Date: ________________ Marked for: _____________________________________
CANE/CRUTCH HOLDEROptional. Only one cane/crutch holder can be used at a time.
COMMENTS
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
BRANCH PATCHESOptional.
Air Force Patch ............................... $20Part: ACC140240
Army Patch ..................................... $20Part: ACC140241
Coast Guard Patch ........................ $20Part: ACC140239
Marines Patch ................................. $20Part: ACC140243
Navy Patch ...................................... $20Part: ACC140244
Purple Heart Patch ........................ $20Part: ACC140238
LAP BELTSOptional.
© 2017 Pride Mobility Products Corp. All rights reserved.
youtube.com/pridemobility
facebook.com/PrideMobilityProductsCorp
twitter.com/pridemobility
instagram.com/PrideMobilityProducts
Wishbone Crutch Holder .................................................... $98Part: FRMASMB2358
Quad Cane Holder ............................................................... $98Part: ACCASMB1931
Single Rear Mount, 3" ..........................................................$70Part: ACCINDV1058
Double Rear Mount, 3" .........................................................$70Part: ACCINDV1019
50" Lap Belt ...............................$39.90 Part: ACCBELT1000
60" Lap Belt ...............................$39.90 Part: ACCBELT1002
70" Lap Belt ...............................$39.90 Part: ACCBELT1003
ACCESSORIES Continued
Back Mounted Accessories
Rear Basket (15.25" x 9.75" x 9.5") .................................... $80 Part: ACCBSKT1010
Oxygen Holder ..................................................................... $98Part: ACCASMB1017
Walker Holder ....................................................................... $98Part: ACCASMB1018
Optional. Only one back mounted accessory can be used at a time. Includes mounting bracket and hardware.
