PinDot Series ContourU Order Form

1 PinDot Series ContourU Order FormSend Cast / Splint and Order form to PinDot Custom SeatingAttn: ContourU , 899 Cleveland St. Elyria, OH 44036 For Skribbl'r Digitizing Systems: E-mail Order form and Digitized File to:Molding Bag MeasurementsMobility Base Information / Cushion DimensionsIs This Order Going "With Chair" (NEW Invacare Chair) *Is This Order Going "On Chair" (NEW Invacare Chair) ** When ordering cushions "With Chair" / "On Chair" fax thisCenter Shapes orLeave as Marked Order form and the Order for the Invacare Chair to: PinDot Customer Service at 1-800-834-4153If Invacare quote is to be converted to Order , please provide Invacare quote # AccessoriesHR01S*Small Headrest includes Adapter PlateSB05 ContourU Pelvic StrapHR02S*Large Headrest includes Adapter PlateAR20 Desk Length Armrest (Pair)HR03S* 2-Step Headrest includes Adapter PlateAR24 Full Length Armrest (Pair)HR04S*Curved Headrest includes Adapter PlateLB07 Small Footrest (Pair)HR15 Headrest Adapter Plate* **LB08 Large Footrest (Pair)* HR15 Required when using Contour U panLT06 Legrest Tops (Pair)

2 ** Will not work with Freedom t-nut patternGL01 Regular LinksTR40L Tray Receptacle - LeftGL03 Extra Strong LinksTR40R Tray Receptacle - RightGL10 Dial Links - Required if seat to back angle is > 105 Seat to Back Junctions Comments and Special InstructionsFullTongueStyle of Gap$ / (1)Top of Lateral Height-LeftN/AFixed Recline (>105)Center Lines:$ $ ease of ordering, contact PinDot Customer Service Toll Free at: 800-451-3553 Fax: 800-834-4153 Cell Phone Number:Modify To: N/AFrame Width:Company Name:Best Time to Contact:Ship To Address:E-mail Address:City/State/Zip:Phone Number:Purchase Order #:Certification #:Fax Number:Account #:Penny Location/ # of PenniesDescriptionMolding Bag:Client Reference:A / (2)Chest WidthN/AB / (2)Waist WidthC / (2)Hip WidthD / (1)Leg Length / RightBack HeightG / (1)Top of Lateral Height-RightF / (1)Seat-Back Angle, in Degrees = inininininBack Tube Diameter:Seat Cushion Width:Frame Depth:inN/AE / (1)Leg Length / LeftN/APelvic ControlGrowth in Angle UniversalN/A$ ControlYesBrand:Back Cushion Width:Inside Back Cane Width:ininInside Rail Width.

3 Seat Tube DiameterModel:$ $ $ to RearTongueInches of Gap$ $ $ $ $ OnlyStd.$ $ Only$ $ Rev. 5/1/12 form Rev. 10/1/12C u s t om Sea t i n gSeat Cushion SpecificationsStandard FoamSoft FoamCovering OptionsCM02S Naked (Drawstring Cloth Cover Included) MountingOptional Cover StyleDraw String (Std)If Leg Length Discrepancy, Size Pan to fit: 2 Piece w/VelcroShort Leg orLong Leg CTNPP indot to cut pan to fit Long Leg Mounting HardwareCM06T Wood Mount with T-Nuts Seat ModificationsCM22 Rail Cut - Finished Rail Cut Width ="CM38 Loose Fit (1/4" Increments)"CM13 Undercut - Right"CM13 Undercut - Left"Show Placement on Cast/Image for These Modifications.

4 CM40 Diagonal Cut Provide DimensionsCM12 Pelvic Strap Notches, 2" StandardCM33 Cross-Brace Notches, Provide DimensionsCM17 Notched Rear CornersCTNPP indot to cut pan for notched cornersCM50 Laminated ReinforcementCM20 Strap Slots 1/2" x 1 1/2" Standard - Naked OnlyCM80 Aluminum ReinforcedCM23 Front Rigging NotchesVF05 Visco Foam Overlay 1/2"SF05 Standard Sofspot Foam Overlay 1/2"VF01 Visco Foam Overlay 1"SF01 Standard Sofspot Foam Overlay 1" Comments and Special InstructionsFor Office use OnlyWidth:CM37 Raisedinches$ $ $ $ $ Duplicate Sofspot Pad (Vinyl Only)CM09V Sofspot - Visco FoamQty:$ $ Wood Mount without T-NutsCM31 Upholstered Bottom without VelcroSeat Width: $ Wood Mounting Kit - 1 inch$ J & L Brackets -1 inch (railcut recommended)$ $ Cushions$ Pan Mounting Kit - 7/8 inchTFEP To Fit Existing Pan: QtyOCMK78 J & L Brackets-7/8 inch (railcut recommended)$ PolartekCM03 Untrimmed (vinyl only)inchesCM30 Recess OnlyQty:inches$ $ :CM34 ExtendedFabric.

5 PGV Purple Gray VinylBKV Black Vinyl$ Wedgewood Blue Vinyl$1, Vinyl Upholstery (Non Removable)Length:Depth:Splint# of Cushions:$ Sofspot - Std FoamQty:L-06 Gray Rubber Backed Lycra$ Pan Mounting Kit - 1 inchCMS LycraDT-2R Reversed Dartex L-19 Burgundy Rubber Backed LycraL-18 Purple Rubber Backed Lycra$ Wood Mounting Kit - 7/8 inchL-23 Green Rubber Backed Lycra$ Red Rubber Backed LycraCMD Darlexx Qty$1, Recess with Gel Pad Insert - Naked Only Serial Number:$ $ :$ or 2 inchDepth:VH02 Vent Holes - Naked Only1 or 2 inchL-20 Blue Rubber Backed LycraL-13 Light Blue Rubber Backed LycraDT-2 Standard Dartex L-05 Black Rubber Backed LycraCM46 As Molded$ Additional Cloth Covers$ Raised$ Non-Std T-Nut Pattern: inchesSAV Sage Green VinylTAV Taupe VinylGMV Gunmetal Gray VinylCM76S Additional Cover for Naked CushionCM78S Additional Cover for Vinyl CushionQtyCM31V Upholstered Bottom with Velcro$ $ Length:$ As Molded$ $ $.

6 $ $ $ ReinforcementinchesCM36 ExtendedinchesCM54 As Molded AbductorCM48 Standard L - Shaped ReinforcementCM47 Raised$ - LeftAdductor - RightSO40 Inner Moisture Resistant CoverTFNP New Pan$ ExtendedL-15 Teal Rubber Backed Lycra$ Spacer Mesh Fabric $ Date:1 or 2 inchCastDigital FileWidth:Length:Rail Cut:Long / Short:After Roll:Overlays only available on Naked CushionWhen opting for a 2-tone fabric selection indicate "A" for contact surface, "B" for non-contact surfacesBack Cushion SpecificationsStandard FoamSoft FoamCovering OptionsCM02B Naked (Drawstring Cloth Cover Included)Optional Cover Style:Draw String (Std)2 Piece w/Velcro Mounting Mounting HardwareCM06T Wood Mount with T-NutsFDI-596 Econo-Eze (Back Only, not recommended with PinDot Pan)Specify Non-Std T-Nut Pattern:Headrest Pattern.

7 Back ModificationsCM22 Rail Cut - Finished Rail Cut Width ="CM38 Loose Fit (1/4" Increments)"CM13 Undercut"CM40 Diagonal Cut"CM20 Strap Slots 1/2" x 1 1/2" Standard - Naked OnlyCM39 Laminated ReinforcementCM21 Aluminum ReinforcedCM534R Swing Away Lateral Right (Naked Only)**CM534L Swing Away Lateral Left (Naked Only)**VF05 Visco Foam Overlay 1/2"SF05 Standard Sofspot Foam Overlay 1/2"VF01 Visco Foam Overlay 1"SF01 Standard Sofspot Foam Overlay 1" Comments and Special InstructionsFor Office use OnlyForm # Placement on Cast/Image for These Modifications$ J & L Brackets-7/8 inch (railcut recommended)$ :Qty:1 or 2 inchDepth.

8 1 or 2 inchinchesCM49 As MoldedLateral - LeftCM52 Extend Existing ShapeL-23 Green Rubber Backed Lycra$ Wood Mounting Kit - 7/8 inch$ $ Teal Rubber Backed LycraHWPMK01 Pan Mounting Kit - 1 inchHWABK Adjustable Back Mounting HardwareHWPMK78 Pan Mounting Kit - 7/8 inchHWWMK01 Wood Mounting Kit - 1 inch Additional Cloth CoversBack Height:$ $ $ Additional Cover for Naked CushionTAV Taupe VinylPGV Purple Gray VinylSAV Sage Green VinylQtyTFEP To Fit Existing Pan: TFNP New PanClient:CM30 Recess OnlyQty:OCMK01 J & L Brackets -1 inch (railcut recommended)$ $ As MoldedQty:CM30G Recess with Gel Pad Insert - Naked OnlyCM09 Sofspot - Std Foam$ $ Vent Holes - Naked OnlyCM51 Square PullLateral ReinforcementCM16 Standard L - Shaped ReinforcementDT-2 Standard Dartex $1, Red Rubber Backed LycraCM01B Vinyl Upholstery (Non Removable)CM78S Additional Cover for Vinyl CushionFabric: SO40 Inner Moisture Resistant CoverGMV Gunmetal Gray VinylBKV Black VinylWWV Wedgewood Blue VinylBack Width: QtyTFCS-Fit to Custom Shell.

9 Lateral - RightCM03 Untrimmed (vinyl only)$ Upholstered Bottom with Velcro$ $ $ Purple Rubber Backed Lycra$1, Reversed Dartex $ Light Blue Rubber Backed LycraSplintReturned Cushionsinchesinches$ LycraCMD Darlexx L-24 Spacer Mesh Fabric L-06 Gray Rubber Backed Lycra$ $ $ $ ** Swing Away Laterals must: 1) Be accompanied by CM21 & CM06T. 2) Not be used with CM22. 3) Be 7" or deeper, from the back of the cushion to the apex of the lateral. 4) Recommended for one side or 2 inchDepth:$ $ $ Sofspot - Visco FoamCM09P Duplicate Sofspot Pad (Vinyl Only)L-05 Black Rubber Backed LycraL-20 Blue Rubber Backed LycraL-19 Burgundy Rubber Backed LycraQtyCMP Polartek$ $ $ Upholstered Bottom without Velcro$ $ Wood Mount without T-Nuts