MAPPS

Mobility and Postural Positioning Specialists

Request a Quotation

Quote form

Please feel free to fill out the form below

Or, you can download one, fill it out and fax it back to us on: 07 871 9584.
It is a 3-page PDF (337kb), so you may require Adobe Acrobat Reader.

 

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Quotation form

Client Information

Therapist name

   

Therapist email

Therapist number

Funding agency

Claim Number

Client name

Client age

Client address
 
 
 

Proposed address for fabrication of equipment
 
 

Any additional informtion
 
 
 

Sizing

sizing chart

1

1

1

2

2

2

3

3

3

4

4

4

5

5

5

6

6

6

7

 

7

Pelvis

Tilt

Flexible Fixed Posterior Neutral Anterior  

Obliquity

Flexible Fixed Down Left Neutral Down Right  

Rotation

Flexible Fixed Post Left Neutral Post Right  

Spine

Scoliosis

Yes No Flexible Fixed Concave from: Left Right Region:

Kyphosis

Yes No Flexible Fixed

Lordosis

Flexible Fixed Increased Decreased Neutral

Please indicate any issues with the following:

Joint ROM
 
 
 

   

Head control
 
 
 

Skin integrity
 
 
 

Equipment information

Proposed Wheelchair:

Make/Model Width Depth

Features to be quoted:

Base cushion Back support  

If maintaining part of the client’s current seating, please indicate what this is:

   

Solid base

Yes No If yes - flat pan on seat rails Drop base:  1”  2”

ABS Rigidiser

Yes No

Leg adductors

Yes No

Pommel

Yes No If yes - swing down Incorporated into cushion Other:
      Therapist to supply Type:

Back support

  Planar Contoured foam Foam in place

Laterals

  Fabricator to supply Therapist to supply Type:
    Incorporated into seat back Fixed bracket:  Left  Right Swing away:  Left  Right

Headrest

Yes No Fabricator to supply Therapist to supply Type:

Covers

Extra cover

Armrests

  Specific adaptation

Legrests

  Specific adaptation

Hip strap

  Fabricator to supply Therapist to supply

Shoulder straps

Yes No Fabricator to supply Therapist to supply Type:

Important notes

1. MAPPS will use as standard the following items in fabrication. If you wish to have alternatives, please indicate this on this form.

  • ABS (custom shaped) fixed laterals
  • AEL swing away Laterials with custom pads
  • Headreast(custom) with AEL bracketry
  • Pommel (swing down) with AEL bracketing
  • Hip Strap Motion Concepts 2/4 point
  • Shoulder Straps (custom back pack) 50mm/25mm
  • Dartex covers with one extra base cove

2. Please ensure that all anticipated requirements are on this form to allow accurate quoting. MAPPS understands that at the time of fabrication alternatives to the quoted requirements may be required and if this incurs a further cost, a new or extra quote will be provided.