Quantum
401 York Ave., Duryea, PA 18642
Phone: 866-800-2002 | Fax: 866-707-3422 | Email: quantumorders@pridemobility.com
Q6 Edge
2.0 Order Form with Pediatric TRU-Balance
®
Account Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
INTRODUCTION
This form is interactive when viewed with
tions other than Acrobat.
Complete the form by placing checks in the desired boxes and provide information in the interactive
fields. Buttons shown at the bottom of the form may be utilized to print or submit the order form through a desktop email
application. To email via a web-based application, please 'Save As' and attach the PDF to your email.
This order form contains a large variety of options to fulfill various patient needs. Descriptions and section notes, such
as optional or required, are included to help you complete your order. Please contact Quantum Sales at 866-800-2002 if
assistance is needed. Send the completed order form by fax (866-707-3422) or email (quantumorders@pridemobility.com).
Incomplete forms may delay the quote or order. Customer service will contact you if the order is incomplete or if there are
compatibility issues.
If special order requests are needed, be sure that the Patient Information section is completed or include a completed
physical assessment form
HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers
are responsible for determining the appropriate billing codes when submitting for insurance reimbursement. Payer coding,
coverage, and bundling guidelines may apply. All prices are MSRP. Prices, specifications, part numbers, and availability
are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete
power chair. Please contact technical service for accurate parts ordering. Options noted with "XRef" have multiple possible
part numbers based on system configuration. Please see
PATIENT INFORMATION
Weight:________ Height:________
INFINFB3537/RevF/05OCT2017
Rehab
®
Adobe Acrobat Reader
with this order form.
Thank you for choosing Quantum!
A. Shoulder Width: _______
B. Chest Width: _________
C. Hip Width: ___________
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and may not function correctly if opened with applica-
cross-reference spreadsheet
D. Max Sitting Height: ____
E. Shoulder Height: ______
F. Axilla Height: _________
3 Positioning
®
for the XRef part numbers.
G. Thigh Depth: _________
H. Lower Leg Length: ____
I. Elbow Height: ________
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