The Freestyle M11 form is a versatile and user-friendly form that can be used for a variety of purposes. It is designed to be easy to fill out, and its intuitive layout makes it simple to navigate. The form can be used for data collection, customer surveys, event registrations, and more. Additionally, the Freestyle M11 form can be customized to suit your specific needs. So if you're looking for a versatile and easy-to-use form, the Freestyle M11 is the perfect choice.
| Question | Answer |
|---|---|
| Form Name | Freestyle M11 Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | M11, ELR, NC, m11 form |
Quickie Freestyle M11 with Perfect FitTM Seating
EIPW8, EFFECTIVE NOVEMBER 2005
ORDERING INFORMATION PHONE: (800)
ACCOUNT INFORMATION
Account No: ___________________________________________________
Date: __________________________________________________________
P.O. #: ________________________________________________________
Buyer: ________________________________________________________
Marked For: ____________________________________________________
FREESTYLE M11
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135PC16 |
K0011 |
Freestyle M11 Standard Chair 6 |
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$5,245.00 |
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Standard Chair |
300 lb 5.5 mph power wheelchair |
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High Back Comfort Seat 6 |
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VSI |
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Upgraded Seating |
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135ST38 |
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Perfect FitTM Adjustable Seat Frame |
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$475.00 |
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Shroud Color |
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Std |
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All Colors Included: Candy Red, Blue, Black & Champagne |
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Drive Wheel |
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135DW1 |
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10" Alum Rim w/Pneumatic Tire |
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NC |
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135DW2 |
K0093 |
10" Alum. Rim & Solid Insert |
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$220.00 |
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User Weight |
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Less than 150 Lbs |
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151 - 250 lbs |
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251 - 300 lbs8 |
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ELECTRONICS |
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Joystick |
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135J23 |
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Integral VSI |
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Std |
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135J23 |
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Integral VSI |
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$200.00 |
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135J5 |
E2320 |
Qtronix Remote |
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1 |
$825.00 |
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135J4 |
E2320 |
Qtronix Remote with 1/8" jacks |
$985.00 |
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Joystick Mount |
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135JM1 |
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Fixed Mount |
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NC |
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135JM2 |
E1028 |
Swing Away Mount |
2 |
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$235.00 |
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135JM3 |
E1028 |
Center Mount Swing Away |
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$235.00 |
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Hand Mount |
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135HM2 |
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Left |
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NC |
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135HM1 |
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Right |
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NC |
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Height Adjustable Mount |
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135HI01 |
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Fixed Mount (Std) |
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NC |
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135HI02 |
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Height Adjustable Mount |
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$95.00 |
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Joystick Handle |
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135JH3 |
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Stick Handle |
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NC |
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135JH1 |
E2323 |
Ball Handle |
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$75.00 |
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135JH2 |
E2323 |
Foam Ball Handle |
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$75.00 |
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135JH4 |
E2323 |
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$75.00 |
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Drop Ship/Ship To: _______________________________________________
Name: __________________________________________________________
Address: ________________________________________________________
City:State:_________________
Zip Code:____________ Phone Number:______________________________
The Perfect FitTM power seating system is a unique, modular and adjustable system that can easily accommodate changes in a User’s power mobility requirements:
-Seating can be adjusted when a User’s physical attributes change
-Power seating options can be be added as needed
-Proper fit for lower and upper body positioning is achieved independently to create the "perfect fit".
PERFECT FITTM POWER SEAT OPTIONS
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135PA4 |
E1007 |
CG Tilt 50°& Pwr Recline, Mech. Shear2,8 |
$ |
9,995.00 |
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135PA1 |
E1002 |
Power CG Tilt 50° |
$ |
5,350.00 |
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135PA3 |
E1004 |
Perfect FitTM Pwr Recline, Mech. Shear2,8 |
$ |
5,850.00 |
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POWER SEAT OPTION ELECTRONICS |
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135TC1 |
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Dual Toggle Activation & Control 4 |
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Std |
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135TC5 |
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Omit Dual Toggle 4 |
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135TC6 |
E2310 |
Thru Drive 1 Power Seat Opt |
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$800.00 |
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135TC10 |
E2311 |
Thru Drive 2+ Power Seat Opt 5 |
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$1,550.00 |
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BATTERIES |
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Batteries |
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135A46 |
E2365 |
U1 Gel Cell (Pair) |
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$230.00 |
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135A150 |
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40 Ahr AGM (Pair) |
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$290.00 |
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Battery Charger |
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135BJ6 |
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4A Charger |
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NC |
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135BJ5 |
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4A Dual Mode |
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$310.00 |
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Battery Straps |
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135BK6 |
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Battery Straps w/insert (U1 & 40Ahr) |
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NC |
* K0011 when supplied with seat and necessary components
FOOTNOTES:
1Two single switches required to operate both the on/off and mode select functions.
2Not available with Integral Joystick.
3VSI controller is a 50A with a 20A boost.
4Dual Toggle not available with Power Legrests
5Requires Qtronix Remote Joystick
6Comfort Seat and Fixed Rehab Seat Sizes Listed on Freestyle Price List 931170
7No Charge if Thru Drive 1 Power Seat Opt is Selected
8Power Recline not available with user weight above 250lbs.
PROPER USE OF HCPCS CODES DOES NOT ENSURE COVERAGE OR PAYMENT. FOR COVERAGE INFORMATION , VERIFY THE APPROPRIATE PAYER’S COVERAGE POLICY.
Specifications are subject to change without notice. Copyright @ 2005, Sunrise Medical. (11.05) Quickie Freestyle M11 - 931508 Rev G. Page 1 of 4
Quickie M11 with Perfect Fit, November 2005
ADJUSTABLE INTEGRATED SEATING
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135CU1 |
2" Cushion |
$95.00 |
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Seat Width Range - Small - Adjustable 12" to 17"
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135S3 |
12" |
NC |
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135S4 |
13" |
NC |
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135S5 |
14" |
NC |
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135S6 |
15" |
NC |
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135S7 |
16" |
NC |
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135S8 |
17" |
NC |
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Seat Width Range - Regular - Adjustable 15" to 20"
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135S6 |
15" |
NC |
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135S7 |
16" |
NC |
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135S8 |
17" |
NC |
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135S9 |
18" |
NC |
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135S10 |
19" |
NC |
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135S11 |
20" |
NC |
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Seat Depth |
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135SD5 |
12" |
NC |
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135SD6 |
13" |
NC |
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135SD7 |
14" |
NC |
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135SD8 |
15" |
NC |
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135SD9 |
16" |
NC |
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ADJUSTABLE INTEGRATED BACK
Back
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135BT72 |
E2613 Contour Posterior Positioning Back |
$ |
475.00 |
Options for Back |
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135KZ2 |
E1225 Manual Recline to 40° |
$ |
175.00 |
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135PH7 |
$ |
100.00 |
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Back Width - Small - Adjustable |
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135BN1 |
12" (Only w/ Shortest Back Ht) |
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$100.00 |
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135BN2 |
13" (Only w/ Shortest Back Ht) |
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$100.00 |
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Back Width - Regular - |
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135BN3 |
14" |
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NC |
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135BN4 |
15" |
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NC |
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135BN5 |
16" |
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NC |
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135BN6 |
17" |
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NC |
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135BN7 |
18" |
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NC |
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135BN8 |
19" |
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NC |
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Back Width - Large - |
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135BN6 |
17" |
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NC |
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135BN7 |
18" |
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NC |
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135BN8 |
19" |
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NC |
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135BN9 |
20" (Not Available on Power Recline) |
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NC |
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Back Height (Measured from Top of Seat Pan to Top of Back) 1
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135SD10 |
17" |
NC |
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135SD11 |
18" |
NC |
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Back Recess 2 |
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135OF1 |
0" |
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135OF2 |
1" |
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135OF3 |
2" |
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135OF4 |
3" |
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3 |
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135AY2 16" 6 135AY4 17" 6 135AY6 18"
135AY8 19" 135AY10 20" 135AY12 21" 135AY13 22"
135AY15 23"
135AY17 24"
135AY19 25"
135AY21 26"
135AY24 27"
135AY23 28"
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135OF5 |
4" |
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Seat Height (at 0 degrees) |
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135HT8 |
17"9 |
NC |
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135HT10 |
18"8 |
NC |
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135HT12 |
19"8 |
NC |
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135HT14 |
20"9 |
NC |
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135FA10 |
0o |
NC |
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135FA3 |
3o |
NC |
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135FA4 |
6o (Not available with power seating) |
NC |
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135FA5 |
9o (Not available with power seating) |
NC |
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FOOTNOTES:
1There is a minimum gap of between the seat pan and the bottom of the back to allow for recline. It is between .5" and 3.5" on the manual back and 2.5" to 4" on the power recline with shear reduction.
2"Recess", moves seatpan forward relative to back.
34" Recess only available with 12", 15", and 18" seat depths
4Not available on Reclining Height Adjustable Armrest.
5To be used with Otto Bock Forearm Pads.
6Not available with Power Recline
7Not available with Manual Adjustable Back
8Add 1/2" for Power Tilt and Power Recline Combination
9 Not Available with Power Tilt
ARMRESTS (pr)
Armrest (NC on Perfect Fit Power CG Tilt or Power Recline)
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135AA70 |
E0973 |
PF Flip Back Ht |
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$250.00 |
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Reclining Height Adjustable7 |
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135AA60 |
E0973 |
Std Height (10.8" - 14") |
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$250.00 |
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135AA61 |
E0973 |
Tall Height (12.8" - 16") |
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$250.00 |
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135AA14 |
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Omit Armrests |
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NC |
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135SG17 |
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Removable Sideguards |
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$120.00 |
Armpads (pr) |
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135AE01 |
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Desk Length Waterfall (10") |
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4 |
NC |
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135AE02 |
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Full Length Waterfall (14") |
4 |
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NC |
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135AE03 |
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Desk Length Standard (10") 4 |
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$15.00 |
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135AE04 |
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Full Length Standard (14") 4 |
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$15.00 |
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135AE05 |
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Reclining Arm Pad (16") 7 |
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NC |
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135AE09 |
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Omit Arm Pad |
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NC |
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Otto Bock Armpad Options |
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135AE08 |
K0106 |
Otto Bock Sm forearms pads (8") |
$240.00 |
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135AE06 |
K0106 |
Otto Bock Med forearms pads (11.5") |
$240.00 |
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135AE07 |
K0106 |
Otto Bock Lg forearms pads (14") |
$240.00 |
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Otto Bock Hand Pads 5 |
(pr) |
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135OL01 |
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Medium Flat Hand Pads |
$105.00 |
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135OL02 |
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Large Flat Hand Pads |
$105.00 |
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Specifications are subject to change without notice. Copyright @ 2005, Sunrise Medical. (11.05) Quickie Freestyle M11 - 931508 Rev G. Page 2 of 4
Quickie M11 with Perfect Fit, November 2005
FOOTRESTS
Hanger
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135H2 |
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70° Swing Away (A,B,C) |
NC |
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135H54 |
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Fixed Center Mount (Inc. Footplate)1,11 |
$250.00 |
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135H55 |
E0990 |
Manual Elevating SA (A,B,D) |
$270.00 |
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135H56 |
E1010 |
Powered Elevating System 2,7,12(B) |
$1,440.00 |
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135H57 |
E1010 |
Powered ELR/ALR System 2,7,12(B) |
$1,880.00 |
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135H32 |
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Omit Hangers |
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Extension Tube 3 |
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135E1 |
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Short (13" - 15") |
NC |
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135E2 |
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Medium (15" - 18") |
NC |
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135E5 |
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Long (18" - 20") |
NC |
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135E33 |
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Power Artic. ELR Med |
NC |
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135E34 |
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Power Artic. ELR Long |
NC |
Foot Plate (pr) |
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135F1 |
Composite w/Heel Loop |
NC |
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A |
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135F3 |
Adult Angle Adjustable w/Heel Loop (pr) |
$210.00 |
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B |
K0040 |
Angle Adjustable Footplate |
$165.00 |
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E0951 |
Heel Loop |
$45.00 |
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135F9 |
Kids Angle Adjustable w/Leg Strap (pr) |
$195.00 |
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C |
K0040 |
Angle Adjustable Footplate |
$165.00 |
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K0038 |
Leg Strap |
$30.00 |
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135F5 |
Aluminum |
$30.00 |
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D |
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135F6 |
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Omit Foot Plate |
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Footrest Accessories |
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135A54 |
K0038 |
Extra Leg Strap, Black |
$30.00 |
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135A110 |
E0952 |
Toe Loop 3 |
$45.00 |
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POSITIONING OPTIONS |
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Headrest (Included on Specialty Controls) |
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135HE1 |
Headrest 8" x 4.5" |
$450.00 |
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E0955 |
Curved Headrest 8" x 4.5" |
$225.00 |
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E1028 |
Removable Mount |
$225.00 |
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135HE2 |
Headrest 9" x 4.5" |
$450.00 |
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E0955 |
Curved Headrest 9" x 4.5" |
$225.00 |
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E1028 |
Removable Mount |
$225.00 |
Traditional Thoracic Lateral Supports |
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135ZU03 |
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Fixed Mounting Hardware |
NC |
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135ZU04 |
E1028 |
Integrated Swing Away Mount |
$220.00 |
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Traditional Lateral |
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135KD5 |
E0956 |
Medium 5" x 5" (PR) |
$220.00 |
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135KD7 |
E0956 |
Large 6" x 6" (PR) |
$220.00 |
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135ZU05 |
E1028 |
$250.00 |
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135ZU06 |
E1028 |
$260.00 |
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135ZU07 |
E1028 |
$260.00 |
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135KD6 |
E0956 |
Small 4" x 4" (PR) |
$200.00 |
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135KD5 |
E0956 |
Medium 5" x 5" (PR) |
$200.00 |
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135KD7 |
E0956 |
Large 6" x 6" (PR) |
$200.00 |
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Lateral |
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135KT01 |
E1028 |
Swing Away Mount 2" Offset (PR) |
$240.00 |
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135KT02 |
E1028 |
Swing Away Mount 4" Offset (PR) |
$240.00 |
Knee Adductor Pads
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135KS01 |
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Small 4" x 4" (PR) |
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$200.00 |
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135KS02 |
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Med 5" x 5" (PR) |
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$200.00 |
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135KS03 |
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Large 6" x 6" (PR) |
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$200.00 |
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ACCESSORIES |
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Backpack |
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135A1 |
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Black Utility |
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$55.00 |
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135A2 |
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Black/Charcoal Kids |
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$50.00 |
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135RB1 |
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$75.00 |
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Auxiliary Control |
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135A42 |
E2351 |
Auxiliary Control Module |
8 |
$795.00 |
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135A44 |
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$60.00 |
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135A43 |
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9 Pin Output Cable |
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$60.00 |
Attendant Control |
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135A450 |
E2331 |
Attendant Drive Control |
9 |
$795.00 |
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Positioning Belt (Seat Frames Only) |
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135A155 |
E0978 |
Auto Style Buckle |
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$50.00 |
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135A12 |
E0978 |
Belt 2" Aircraft Buckle |
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$85.00 |
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135A13 |
E0978 |
Belt 2" Aircraft Buckle Padded |
$115.00 |
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Wheelchair Tray Table |
10 |
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135A31 |
E0950 |
Medium Tuffak |
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$225.00 |
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135A32 |
E0950 |
Large Tuffak |
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$225.00 |
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135A33 |
E0950 |
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$225.00 |
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Programmer |
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135PR1 |
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Qtronix Programmer Pad |
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$525.00 |
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FOOTNOTES:
1This center mount is attached to seat frame as opposed to base.
2Order with Power ELR/ALR extension tubes.
3Only available with adult angle adjustable footplates.
4Only available with SA Power ELRs and Power ELR/ALRs
5Not available with 12, 13 or 14 wide seats.
6Only available with Fixed Center Mount Footrest.
7No Charge for Angle Adjustable footplate included
8Requires USCM
9Mount Available for Seat Frames Only. Not available with Integral Controller.
Operates drive only, no power seat options.
10Requires Standard Armpads. Not available with the Reclining Height Adjustable Armrest.
11Leg Length
12Requires Qtronix Remote Joystick
QUICKIE FREESTYLE M11 w/ PERFECT FIT SPECIFICATIONS
Maximum rider weight 300 lbs
Chair Weight: 139.9 lbs. Without batteries and footplate
User Weight: Maximum 300 lbs.
Width: 22.5"
Length: 32" (without Footplate) 38.5" (with Footplate)
Range: Up to 20 miles. Top Speed: Up to 5.5 mph
Casters: 6"
Order Form Measurments: Dimensions ±.5"
Weights ±10%
Degrees ±3°
Specifications are subject to change without notice. Copyright @ 2005, Sunrise Medical. (11.05) Quickie Freestyle M11 - 931508 Rev G. Page 3 of 4
Quickie M11 with Perfect Fit, November 2005
SPECIALTY INPUT INDIVIDUAL COMPONENTS
Specialty Input Interface |
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135AI2 |
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USCM Left, Swing Away Mount |
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$1,490.00 |
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135AI1 |
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USCM Right, Swing Away Mount |
$1,490.00 |
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135AI4 |
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USCM & Omit Mount |
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$1,470.00 |
Specialty Input Device |
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Requires USCM |
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135ID6 |
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$150.00 |
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135ID9 |
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Mini Proportional Joystick 1 |
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$780.00 |
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135ID10 |
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Penta Switch |
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$200.00 |
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Single Switch |
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135SW1 |
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Buddy Button Switch |
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$55.00 |
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135SW2 |
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Disc Switch |
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$120.00 |
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135SW10 |
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Egg |
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$95.00 |
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135SW4 |
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Micro Light Switch |
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$75.00 |
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135SW6 |
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Ribbon Switch |
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$45.00 |
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135SW9 |
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Wobble Switch |
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$200.00 |
Specialty Input Accessories |
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135SA01 |
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Drive Input Device Switch Box |
2 |
$750.00 |
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135SA04 |
E2320 |
Remote Joystick w/Jacks - Swing Away |
$985.00 |
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(For Use with Drive Input Switch Box) |
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135SA03 |
E2320 |
Remote Joystick w/Jacks - Fixed Mount |
$965.00 |
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(For Use with Drive Input Switch Box) |
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Packages Include:
USCM Hand Mount
135UH2 |
Left Side |
NC |
135UH1 |
Right Side |
NC |
Packages
135ID26 |
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$2,795.00 |
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E2325 |
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$1,870.00 |
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E0995 |
Headrest |
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$265.00 |
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E1028 |
Headrest removable Mount |
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$210.00 |
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E2326 |
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$450.00 |
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135ID31 ASL Head Array Package - Adult |
1,3 |
$5,795.00 |
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E2330 |
ASL Proximity Head Array |
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$5,585.00 |
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E1028 |
Head Array Removable Mounting Hdwr |
$210.00 |
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135ID30 |
ASL Head Array Package - Pediatric 1,3 |
$5,795.00 |
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E2330 |
ASL Proximity Head Array |
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$5,585.00 |
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E1028 |
Head Array Removable Mounting Hdwr |
$210.00 |
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135ID13 Switch It Head Array Package - Adult 3 |
$4,390.00 |
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E2330 |
Switch It Proximity Head Array |
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$4,180.00 |
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E1028 |
Head Array Removable Mounting Hdwr |
$210.00 |
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135ID14 |
Switch It Head Array Package - Pediatric 3 |
$4,390.00 |
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E2330 |
Switch It Proximity Head Array |
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$4,180.00 |
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E1028 |
Head Array Removable Mounting Hdwr |
$210.00 |
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135ID28 HMC Mini Joystick Chin/Lip Control Pckg 1 |
$4,595.00 |
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E2320 |
HMC Mini Joystick |
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$4,120.00 |
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E0995 |
Headrest |
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$265.00 |
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E1028 |
Headrest Removable Mount |
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$210.00 |
135ID32 HMC Mini Joystick w/Midline Gatlin Pckg 1 |
$4,595.00 |
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E2320 |
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$4,385.00 |
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E1028 |
Swing Away Mount |
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$210.00 |
135ID33 Penta Switch Package 1 |
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$1,195.00 |
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E2322 |
(No Mount for Penta) |
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135ID12 |
Proportional Head Control Package 1,3 |
$3,795.00 |
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E2327 |
Proportional Head Control |
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$3,585.00 |
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E1028 |
Removable Mount |
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$210.00 |
FOOTNOTES
1Single switch required for mode/stop switch.
2Allows use of a remote and a specialty input device alternatively.
3Solid Backrest must be selected.
Sunrise Medical
7477 E. Dry Creek Pkwy Longmont, CO 80503 (800)
Specifications are subject to change without notice. Copyright @ 2005, Sunrise Medical. (11.05) Quickie Freestyle M11 - 931508 Rev G. Page 4 of 4