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.