M300 Corpus 3G
Display ADP Codes on order/quote:
Three column pricing on order/quote:
Please send order/quote to fax#: (800) 231-3256
Email to:
sales@permobil.com
Dealer Information
* Contact:______________________________
Dealer Code:______________________________
* Dealer Name:______________________________
Address:______________________________
* City:______________________________
* Province:______________________________
* Phone#:______________________________
* Fax#:______________________________
PO#:______________________________
Email Address:______________________________
Client Information
Permobil recommends that the client is evaluated by a
certified rehab specialist.
* First Name:______________________________
* Last Name:______________________________
Diagnosis:______________________________
Funding Source:______________________________
Client Age:______________________________
Client Measurements
* Weight:_______________________________
*Height:_______________________________
A) Top of Shoulders:_______________________________
B) Chest Depth:_______________________________
C) Chest Width:_______________________________
D) Seat Depth:_______________________________
E) Top of Head:_______________________________
F) Elbow to Hand:_______________________________
G) Seat Pan to Elbow:_______________________________
H) Hip Width:_______________________________
*I) Knee to Foot:_______________________________
Prices effective November 4, 2013 and payable in Canadian dollars.
Permobil Ltd.
4 - 75 Mary St.
Aurora, Ontario
L4G 1G3
Tel: (888) 726-9330
CAN Fax: (905) 726-9990
US Fax: (800) 231-3256
www.permobil.com