Amtryke Therapeutic Form – Fill Out and Use This PDF

Recipie t’s Na e:

Age:

Date of Request:

Mailing Address:

Phone #:

City/State/Zip:

Email:

Diagnosis:

If Recipient is Under Age 18

Parent/Guardian Name:

If different from above

Mailing Address:

Phone #:

City/State/Zip:

Email:

Secondary Contact Name:

Phone #:

Treati g Therapist’s Na

e:

Phone #:

Email:

How did you hear about the Amtryke Therapeutic Tricycle? (Check all that apply)

□ Therapist □ Website

□ AMBUCS Member □ Other:

Will you need financial assistance to obtain the tricycle?

□ Yes

□ No

Signature:

Date:

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

This Form, the Assessment Form and Tryke Selection Form must be received by your local chapter or the Resource Center before placement is considered.

Legal Guardian Signature:

Date:

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

This Form, the Assessment Form and Tryke Selection Form must be received by your local chapter or the Resource Center before placement is considered.

Age:

Weight (lbs.):*

Height (inches):*

Diagnosis(es):*

*This private information is only used to help appropriately fit the rider.

RIDER’S MEASUREMENTS

A

Center of Shoulder

B

Center of Elbow

Arm Measurements (inches)

Total Length

C

Center of Digit Crease

Left

A to B:

B to C:

D

Center of Hip

Right

A to B:

B to C:

E

Center of Knee

Trunk

A to D:

F

Bottom of Foot

Leg Measurements (inches)

Total Length

Arm Length & Leg

Left

D to E:

E to F:

Length Measurements

Right

D to E:

E to F:

are critical to correct

Amtryke Selection

Notes on Provided Measurements (if any):

Helmet Sizing

Sizing Chart is

Size

Measurement (head circumference)

available online:

XXS

. ” to

. ”

www.ambucs.org/riders

XS

. ” to

”

/wish-list/sizing-chart/

S/M

” to

. ”

L/XL

. ” to

. ”

Therapist Name:

Is this the treating therapist?

□ Yes

□ No

Credentials:

Phone:

Email:

Facility Name:

Street Address:

City:

State:

Zip:

Is this facility an Amtryke Evaluation Site?

□ Yes

□ No □ Not Sure

Name/Facility:

Phone:

Street Address:

City:

State:

Zip:

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

Step 3: Take rider s

easure e

ts fro

the front of this Assessment Form and compare them to our Sizing Chart.

(This will narrow the choices considerably)

Step 4: Choose a dri

e. (If it does

t

e tio a hoi e, the ig ore this step.

GENERIC ACCESSORIES (not model specific)

Safety Items

□

Safety Flag

□ NEW! Medical Cart

□ Water Bottle w Cage

□ License Plate

(carries 02 bottle/ventilator/tubing)

Leg & Foot Items

□

Foot Cups (pair):

□

Knee Adductor Strap:

□

Pedal Block ( = ¾”

_____qty

□

Small

□

Small

□ Large

□

Medium

□

Medium

Hand Items

□ Variable Range of

□

Wrist Wraps

□

Wrist Brace Mitt:

Motion Kit

(Includes right & left)

□ Right

□ Left

(only for Hand & Foot Cycles)

□ X-Small

□ Large

□

XX-Small

□ Medium

□ Small

□

X-Small

□ Medium

□ Small

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

Snappy Seat Accessories: □ Notched Seat Bottom Cushion*

□ Notched Wide Bottom Cushion*

□ XL Seat Back

□ Laterals

□ H-Harness: □ ” □ . ” *Cannot be used with rear steering

1410 Accessories:

□ Rear Steering Kit

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Laterals

□ H-Harness: □ ” □ . ”

Snappy Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Exercise Pedals

Seat Bottom Alternates:

□ Pommel Saddle Seat □ Mediu

(11.5x10

”

)

□ Skinny Saddle Seat ( . x ”

Trunk Support Upgrades:

□ ProSeries Head Rest □ ProSeries Full Padded Back

□ ProSeries Seatback

backpad & 2 laterals)

(includes push grip,

↴

□ ProSeries Back Spacer Kit

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ”

□ AM Full Padded Back

Bucket Seat Accessories:

□ H-Harness:

□ ” □ . ”

□ Laterals

□ H-Harness: □ ” □ . ”

1412 Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Knee Separator: □ ” □ ”

□ Toe Pedal Leveler Pulley

□ Hand Brake

□ Exercise Pedals

□ Hi-Rise Handlebars: □ ” (BMX

□

”

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

□ 1416 ProSeries FOOT TRYKE (with

” wheels, fixed drive) – 50-FC-1416 Arm Length 14-22”, Leg Length 24-32”

□ Option #1 – Standard Seating System: Saddle Seat with ProSeries Seatback System (Includes push grip, backpad & 2

laterals)

Seat Bottom Alternates:

Bench Seat

Padded Tractor Seat with bracket

Pommel Saddle Seat

Trunk Support Upgrades:

□

□

□ ProSeries Full Padded Back

□

□ Med (11.5x10”) □ Large↴(

x

”)

□ ProSeries Head Rest

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ” □ Recumbent 10 Degree Seat Post

□ Option #2 – Upgraded Seating System: Saddle Seat/1600 Simple Seat Back

”

□ Large

x

”

Seat Bottom Alternates:

□ Padded Tractor Seat with bracket

□ Pommel Saddle Seat □ Mediu

(11.5x10

)

(

)

Trunk Support Upgrades:

□ H-Harness: □ ” □

. ”

□ ProSeries Lumbar Pad

□ Option #3 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories: □ H-Harness: □ ” □

. ”

1416 Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Knee Separator: □

” □

”

□ Calf & Leg Support

□ Toe Pedal Leveler Pulley

□ ” exte der tube

□ Hi-Rise Handlebars: □

” □

”

□ Exercise Pedals

□ Rear Steering Kit (NEW! Takes the place of 1500 Series)

□ 1420 ProSeries FOOT TRYKE (with

” wheels, fixed drive) – 50-FC-1420 Arm Length 18-28”, Leg Length 27-35”

□ Option #1 – Standard Seating System: Saddle Seat with ProSeries Seatback System (Includes push grip, backpad & 2

laterals)

Seat Bottom Alternates:

Bench Seat

Padded Tractor Seat with bracket

Pommel Saddle Seat

Trunk Support Upgrades:

□

□

□

□ Med (11.5x10”) □ Large↴(

x

”)

□ ProSeries Head Rest

□ ProSeries Full Padded Back

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ”

□ Recumbent 10 Degree Seat Post

□ Option #2 – Upgraded Seating System: Saddle Seat/1600 Simple Seat Back

”

□ Large

x

”

Seat Bottom Alternates:

□ Padded Tractor Seat with bracket

□ Pommel Saddle Seat □ Mediu

(11.5x10

)

(

)

Trunk Support Upgrades:

□ H-Harness: □ ” □

. ”

□ ProSeries Lumbar Pad

□ Option #3 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories: □ H-Harness: □ ” □

. ”

1420 Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Knee Separator: □

” □

”

□ Toe Pedal Leveler Pulley

□ Calf & Leg Support

□ Hi-Rise Handle Bars: □ ” □

”

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

Seat Bottom Alternates:

Pommel Saddle Seat

Trunk Support Upgrades:

□ Bench Seat

□ Padded Tractor Seat with bracket

□

□ Med (11.5x10”) □ Large↴( x ”)

□ ProSeries Head Rest

□ ProSeries Full Padded Back

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ”

□ Recumbent 10 Degree Seat Post

Seat Bottom Alternates:

□ Padded Tractor Seat with bracket

□ Pommel Saddle Seat □ Mediu

”

□ Large

x

”

(11.5x10

)

(

)

Trunk Support Upgrades:

□ H-Harness: □ ” □ . ”

□ ProSeries Lumbar Pad

Bucket Seat Accessories:

□ H-Harness: □ ” □

. ”

1420 Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Knee Separator: □ ” □

”

□ Toe Pedal Leveler Pulley

□ Calf & Leg Support

□ Hi-Rise Handle Bars: □ ” □

”

Seat Bottom Alternates

□ Padded Tractor Seat with bracket □ Pommel Saddle Seat □ Mediu

”

□ Large

x

”

(11.5x10

)

(

)

1616 Accessories:

□ ” Hi-Rise Handle Bars

□ 1400 Handlebars

□ Expanding Pedals

Seat Bottom Alternates:

□ Padded Tractor Seat with bracket □ Pommel Saddle Seat □ Mediu

”

□ Large

x

”

(11.5x10

)

(

)

1620 Accessories:

□ ” Hi-Rise Handlebars

□ 1400 Handlebars

□ Expanding Pedals

□ Option #1 – Standard Seating System: Large Saddle Seat (

x ”

Seat Bottom Alternates: □ Bench Seat □ Med Saddle (10.5x10) □ Padded Tractor Seat w/ Support Bracket: □ ” □ ”

□ Pommel Saddle Seat □ Mediu

(11.5x10”) □ Large(

x

”)

Trunk Support Upgrades:

□ 2700 Back Support (with pad & 2 laterals)

Handlebar Upgrades: □ ProSeries Handlebars □ ”Hi-Rise Handlebars

□ Dual Hand Brake Lever □ Stem Riser

2722 Accessories:

□ Exercise Pedals □ Expanding Pedals □ Heel Pedal Leveler Pulley (only w/ Expanding Pedals)

□ Calf & Leg Support (only w/ Expanding Pedals)

□ 2700 Angled Seat Post

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

JT-2000 Accessories:

□ Exercise Pedals

□ XL Exercise Pedals

□ Expanding Pedals □ Digital Speedometer

□ Dual Hand Brake

□ Toe Clips

□ Rearview Mirror

JT-2300-USS Accessories:

□ Exercise Pedals

□ XL Exercise Pedals

□ Expanding Pedals □ Digital Speedometer

□ Dual Hand Brake

□ Toe Clips

□ Rearview Mirror

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Resource Center: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

□ New! AM-10 HAND-FOOT TRYKE (with ”

ra k ar s) 50-HFC-0105 Arm length 12-16”, leg length 14-21”

□ Option #1 – Standard Seating System: Blue Bucket Seat

□ Option #2 – Upgraded Seating System: Snappy Seat System

□ XL Seat Back

Snappy Seat Accessories: □ Notched Seat Bottom Cushion* □ Notched Wide Bottom Cushion*

□ Laterals

□ H-Harness: □ ” □

. ”

AM-10 Accessories:

□ Rear Steering Kit

□ Push Bar

□ Heavy-Duty Push Bar

□ Pull/Steering Bar

*cannot be used with rear steering

□ AM-12Small HAND-FOOT TRYKE (with ” ra k ar

s & ” wheels) 50-HFC-0110 Arm length 12- ”, leg le gth

-

”

Now comes standard with rear steering!

□ Option #1 – Standard Seating System: Bench Seat & 1600 Simple Seat Back

□ Option #2 – Upgraded Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion* □ Notched Wide Bottom Cushion* □ XL Seat Back

□ Laterals

□ H-Harness: □ ” □

. ”

□ Option #3 – Upgraded Seating System: Blue Bucket Seat

AM-12S Accessories:

□ Pull/Steering Bar

□ Toe Pedal Leveler Pulley

□ Exercise pedals

□ Push Bar

□ Heavy-Duty Push Bar *cannot be used with rear steering

□ AM-12 HAND-FOOT TRYKE (with 4” ra k ar

s &

” wheels) 50-HFC-0210 Arm length 14-23”, leg length 21-29”

Now comes standard with rear steering!

□ Option #1 – Standard Seating System: Saddle Seat/1600 Simple Seat Back

”

□ Large

x ”

Seat Bottom Alternates:

□ Bench Seat

↴

□ Pommel Saddle Seat □ Mediu

(11.5x10

)

(

)

Trunk Support Upgrades:

□ ProSeries Head Rest □ ProSeries Full Padded Back

□ ProSeries Seatback

(includes push grip, backpad & 2 laterals)

□ ProSeries Lumbar Pad

□ ProSeries Back Spacer Kit

□ H-Harness: □ ” □

. ”

□ AM Full Padded Back

□ Option #2 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories:

□ H-Harness: □ ” □

. ”

□ Option #3 – Upgraded Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion □ Notched Wide Bottom Cushion □ XL Seat Back

□ Laterals

□ H-Harness: □ ” □

. ”

AM-12 Accessories:

□ Pull/Steering Bar

□ Toe Pedal Leveler Pulley

□ Exercise pedals

□ Knee Separator: □

” □

”

Please mail, email or fax completed form to your local chapter or AMBUCS Resource Center

(800) 838-1845

Mail: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

This form, Request & Liability Waiver Form and Assessment Form must be received before placement is considered.

Recipie t’s Na e:

□ AM-16 HAND-FOOT TRYKE (with ” wheels) 50-HFC-0411 Arm length 18-27”, leg length 24-36”

Now comes standard with rear steering!

□ Option #1 – Standard Seating System: Saddle Seat/Gray Plastic Back

Seat Bottom Upgrades: □ Bench Seat

□ Padded Tractor Seat (used with ProSeries Seatback only)

□ Pommel Saddle Seat □ Mediu

(11.5x10”) □ Large( x

”)

Trunk Support Upgrades: □ ProSeries Seatback

↴

□ ProSeries Head Rest □ ProSeries Full Padded Back

(includes push grip, backpad & 2 laterals)

□ ProSeries Lumbar Pad

□ Proseries Back Spacer Kit

□ H-Harness: □ ” □

. ”

□ AM Full Padded Back

□ Option #2 – Standard Seating System: Saddle Seat/1600 Simple Seat Back

Seat Bottom Upgrades: □ Bench Seat

□ Padded Tractor Seat (used with ProSeries Seatback only)

□ Pommel Saddle Seat □ Mediu

(11.5x10”) □ Large( x

”)

Trunk Support Upgrades: □ ProSeries Seatback

↴

□ ProSeries Head Rest □ ProSeries Full Padded Back

(includes push grip, backpad & 2 laterals)

□ ProSeries Lumbar Pad

□ ProSeries Back Spacer Kit

□ H-Harness: □ ” □

. ”

□ AM Full Padded Back

□ Option #3 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories: □ H-Harness: □ ” □

. ”

AM-16 Accessories:

□ Pull/Steering Bar

□ Toe Pedal Leveler Pulley

□ Exercise pedals

□ XL Exercise pedals

□ Knee Separator: □

” □ ” □ K ee Separator ” Exte der Tube

□ New! AM-20 HAND-FOOT TRYKE (Recumbent Single Speed) – 50-HFC-0610 Arm length 18- ”, leg le gth - ”

AM-20 Accessories:

□ Exercise Pedals

□ XL Exercise Pedals

□ Expanding Pedals

□ Wheelchair Seat Bar Ends

□ Swing Away Arms

Please mail, email or fax completed form to your local chapter or AMBUCS Resource Center

(800) 838-1845

Mail: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

This form, Request & Liability Waiver Form and Assessment Form must be received before placement is considered.

□ Laterals

□ H-Harness: □

” □

. ”

AM-10 Accessories:

□ Push Bar

□ Heavy-Duty Push Bar

□ Pull/Steering Bar

□ Rear Steering Kit

□ AM-12Small HAND TRYKE – (

” Fro t Wheel & Per a e

t Foot Platfor

50-HC-0210S Arm Length 12-16”

Now comes standard with rear steering!

□ Option #1 – Standard Seating System: Bench Seat & 1600 Simple Seat Back

Trunk Support Upgrades:

□ AM Full Padded Back

□ H-Harness: □

” □

. ”

□ Back Spacer Kit

□ Option #2 – Upgraded Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion* □ Notched Wide Bottom Cushion* □ XL Seat Back

□ Laterals

□ H-Harness: □ ” □

. ”

□ Option #3 – Upgraded Seating System: Blue Bucket Seat

AM-12Small Accessories:

□ Pull/Steering Bar

□ Push Bar

□ Heavy-Duty Push Bar

□ Knee Separator: □

” □

”

*cannot be used with rear steering

□ AM-12 HAND TRYKE – (

” Fro

t Wheel & Per

a e

t Foot Platfor 50-HC-0210 Arm Length 14-

”

Now comes standard with rear steering!

□ Option #1 – Standard Seating System: Saddle Seat/1600 Simple Seat Back

(11.5x10

)

(

)

Seat Bottom Alternates:

□ Bench Seat

□ Pommel Saddle Seat □ Mediu

□ Large

”

x

”

Trunk Support Upgrades:

□ ProSeries Head Rest

□ ProSeries Full Padded Back

□ ProSeries Seatback

backpad & 2 laterals)

(includes push grip,

↴

□ ProSeries Back Spacer Kit

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ”

□ AM Full Padded Back

□ Option #2 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories:

□ H-Harness: □ ” □

. ”

□ Option #3 – Upgraded Seating System: Snappy Seat System

Snappy Seat Accessories: □ Notched Seat Bottom Cushion* □ Notched Wide Bottom Cushion* □ XL Seat Back

□ Laterals

□ H-Harness: □ ” □ . ”

AM-12 Accessories:

□ Pull/Steering Bar

□ Knee Separator: □

” □

”

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Mail: P.O. Box 5127, High Point, NC 27262 Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org

This form, Request Form & Liability Waiver Form and Assessment Form must be received before Amtryke placement is considered.

□ AM-16 HAND TRYKE (

” wheels) 50-HFC-0411

Arm length 18-27”

Now comes standard with rear steering!

□ Option #1 – Standard Seating System: Saddle Seat/Gray Plastic Back

Seat Bottom Upgrades: □ Bench Seat

□ Padded Tractor Seat (used with ProSeries Seatback only)

□ Pommel Saddle Seat □ Mediu

(11.5x10”) □ Large( x

”)

Trunk Support Upgrades: □ ProSeries Seatback

↴

□ ProSeries Head Rest □ ProSeries Full Padded Back

(includes push grip, backpad & 2 laterals)

□ Proseries Back Spacer Kit

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ”

□ AM Full Padded Back

□ Option #2 – Standard Seating System: Saddle Seat/1600 Simple Seat Back

Seat Bottom Upgrades: □ Bench Seat

□ Padded Tractor Seat (used with ProSeries Seatback only)

□ Pommel Saddle Seat □ Mediu

(11.5x10”) □ Large( x

”)

Trunk Support Upgrades: □ ProSeries Seatback

↴

□ ProSeries Head Rest □ ProSeries Full Padded Back

(includes push grip, backpad & 2 laterals)

□ ProSeries Back Spacer Kit

□ ProSeries Lumbar Pad

□ H-Harness: □ ” □

. ”

□ AM Full Padded Back

□ Option #3 – Upgraded Seating System: Gray Bucket Seat

Bucket Seat Accessories: □ H-Harness: □ ” □

. ”

AM-16 Accessories:

□ Pull/Steering Bar

□ K ee Separator ” Exte der Tube

□ Knee Separator: □

”

□ ”

□ COMMUNITY CRUISER HAND TRYKE – (

” Fro

t Wheel &

-Speed Drive Train) 50-HC-1424 Arm length 22- ”

CC Accessories:

□ Wheelchair Seat Bar Ends

□ Swing Away Arms

□ Remote location break and shifting kit

□ HP-1000 RECREATION HAND TRYKE – (7-Speed Drive Train) 50-HC-1000

Arm length 22- ”

HP-1000 Accessories:

□ Wheelchair Seat Bar Ends

□ Swing Away Arms

Therapist Assembly Notes or Comments (if any):

Please mail, email or fax completed form to your local chapter or the AMBUCS Resource Center

(800) 838-1845

Mail: P.O. Box 5127, High Point, NC 27262

Email: ambucs@ambucs.org Fax: 336.852.6830

ambucs.org