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SIZE SELECTION 1 LENGTH* FRAME WIDTH 16” 18” 20” 16” 18” 20” 22” 14” 24” 22” VISCO BACK ® ORDER FORM HCPCS CODING: E2611/E2612 GENERAL USE BACK Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: $514.00 $590.00 $439.00 $514.00 Shown with Compass ® 4 Quick Release 2 Point Hardware. *Length (L) refers to the actual size dimension of the support from bottom to top edge. BASE MSRP BY SIZE VISCO-BACK-ORDER REV0316 LENGTH* FRAME WIDTH 16W22L 18W22L 20W22L 22W22L 16W20L 18W20L 20W20L 22W20L 16W18L 18W18L 20W18L 22W18L 16W16L 18W16L 20W16L 22W16L 16W14L 18W14L 20W14L 24W22L 24W20L 24W18L 16” 18” 20” 16” 18” 20” 22” 14” 24” 22” 2 POINT Mounting Hardware Only 4 POINT Only VB-BS Sizes available are subject to hardware being used. IF DESIRED SIZE IS NOT LISTED, PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248 VISCO-BACK ® ORDER FORM Patient Reference: PAGE 1 of 4 Required COVER & HARDWARE SELECTION 2 Required 2.1 COVER SELECTION MSRP $0.00 Both fabrics are latex-free. Fabric selection is for the support surface only. Other fabrics used in cover construction remain the same. COMFORT-TEK™ Cover (COMFORT-TEK) STRETCH-AIR™ Cover (STRETCH-AIR) QUICK RELEASE 2 POINT (Q-COMPASS) QUICK RELEASE 4 POINT (Q-COMPASS4) COMFORT-TEKis a smooth, easily cleaned surface. The fluid protection aids in infection control. STRETCH-AIRhas comfortable stretch, air transmission and heat dissipation. It is not fluid resistant. Please fill in the above with dimensions from the size chart to the right. Example Part: VB-BS16W18L 2.2 HARDWARE SELECTION MSRP $0.00 COMPASS ® 4 QUICK RELEASE 4 POINT TOP VIEW FOR 16W-22W FOR 24W For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then email or print and fax to Customer Service at [email protected] or 1.406.522.8563.

VISCO BACK ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Visco-Back.pdf · visco-back® order form patient reference: page 3 of 4 5

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Page 1: VISCO BACK ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Visco-Back.pdf · visco-back® order form patient reference: page 3 of 4 5

SIZE SELECTION1

LEN

GTH

*

FRAME WIDTH

16”

18”

20”

16” 18” 20” 22”

14”

24”

22”

VISCO BACK®

ORDER FORMHCPCS CODING: E2611/E2612

GENERAL USE BACK

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

$514.00 $590.00

$439.00 $514.00

Shown with Compass® 4 Quick Release 2 Point Hardware.

*Length (L) refers to the actual size dimension of the support from bottom to top edge.

BASE MSRP BY SIZE

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LEN

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*

FRAME WIDTH

16W22L 18W22L 20W22L 22W22L

16W20L 18W20L 20W20L 22W20L

16W18L 18W18L 20W18L 22W18L

16W16L 18W16L 20W16L 22W16L

16W14L 18W14L 20W14L

24W22L

24W20L

24W18L

16”

18”

20”

16” 18” 20” 22”

14”

24”

22”

2 POINT Mounting Hardware Only 4 POINT Only

VB-BSSizes available are subject to hardware being used. IF DESIRED SIZE IS NOT LISTED, PLEASE CONTACT

CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248

VISCO-BACK® ORDER FORM Patient Reference: PAGE 1 of 4

Required

COVER & HARDWARE SELECTION2 Required

2.1 COVER SELECTIONMSRP $0.00

Both fabrics are latex-free. Fabric selection is for the support surface only. Other fabrics used in cover construction remain the same.

COMFORT-TEK™ Cover(COMFORT-TEK)

STRETCH-AIR™ Cover (STRETCH-AIR)

QUICK RELEASE 2 POINT (Q-COMPASS)

QUICK RELEASE 4 POINT(Q-COMPASS4)

COMFORT-TEK™ is a smooth, easily cleaned surface. The fluid

protection aids in infection control.

STRETCH-AIR™ has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant.

Please fill in the above with dimensions from the size chart to the right.Example Part: VB-BS16W18L

2.2 HARDWARE SELECTIONMSRP $0.00

COMPASS® 4 QUICK RELEASE

4 POINTTOP VIEW

FOR 16W-22W FOR 24W

For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then email or print and fax to Customer Service at [email protected] or 1.406.522.8563.

Page 2: VISCO BACK ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Visco-Back.pdf · visco-back® order form patient reference: page 3 of 4 5

VISCO-BACK® ORDER FORM Patient Reference: PAGE 2 of 4

BACK SUPPORT ADD-ON SELECTIONS3 Optional

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3.1 3.2 3.3COLOR EMBROIDERY PRIVACY FLAPMSRP $25.00 MSRP $25.00 MSRP $35.00

Accent colors are applied via colored piping. Placement of the piping may vary by back support size and mounting hardware. If no colors are selected, our standard silver reflective piping is used at no additional cost.

This flap connects with hook & loop attachment between the seat and back for added privacy.

Privacy Flap

Color Location

RED (RED)

PURPLE (PURPLE)

PINK (PINK)

BLUE (BLUE)

GREEN (GREEN)

REMOVE (REMOVE)

PRIVACY FLAP (PV-FLAP)

A. THREAD COLOR OPTIONS

RED (EMB-RED) BLUE (EMB-BLUE)

PURPLE (EMB-PURPLE) GREEN (EMB-GREEN)

PINK (EMB-PINK) SILVER (EMB-SILVER)

B. FONT OPTIONS

Helvetica (EMB-Helvetica) (EMB-Twilight)

Garamond (EMB-Garamond) (EMB-Script)

C. WORD ONE

WORD TWO (optional)

*ADDITIONAL LEAD TIMES MAY APPLY

LATERAL TRUNK SUPPORT & HARDWARE4 Optional

4.1 LATERAL TRUNK SUPPORT PAD STYLE Select a left and/or right lateral trunk support pad using any combination of size, style and fabric.

STRETCH-AIR™

COMFORT-TEK™

has comfortable stretch, air transmission and heat

dissipation.

is a smooth, easily cleaned surface. The fluid protection

aids in infection control.

Contact Customer Service for custom sizes that are not listed below. 1.800.564.9248.HCPCS Code: E0956 MSRP $79.00/ea.

*Length (L) refers to the actual size dimension of the support from top to bottom edge.

L

D

L

D

L

D

L

D

MOLDABLE

RIGID

MOLDABLE ACTIVE

RIGID ACTIVE

4”D x 3”L 5”D x 3”L 5”D x 4”L 6”D x 4”L 6”D x 6”L 7”D x 5”L

COMFORT-TEK LT1-MF4W3T LT1-MF5W3T LT1-MF5W4T LT1-MF6W4T LT1-MF6W6T LT1-MF7W5T

Left Right Left Right Left Right Left Right Left Right Left Right

Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

STRETCH-AIR LT1-MS4W3T LT1-MS5W3T LT1-MS5W4T LT1-MS6W4T LT1-MS6W6T LT1-MS7W5T

Left Right Left Right Left Right Left Right Left Right Left Right

Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

COMFORT-TEK LT1-MF4W3T-AL LT1-MF4W3T-AR LT1-MF5W3T-AL LT1-MF5W3T-AR LT1-MF5W4T-AL LT1-MF5W4T-AR LT1-MF6W4T-AL LT1-MF6W4T-AR LT1-MF6W6T-AL LT1-MF6W6T-AR LT1-MF7W5T-AL LT1-MF7W5T-AR

Left Right Left Right Left Right Left Right Left Right Left Right

Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

STRETCH-AIR LT1-MS4W3T-AL LT1-MS4W3T-AR LT1-MS5W3T-AL LT1-MS5W3T-AR LT1-MS5W4T-AL LT1-MS5W4T-AR LT1-MS6W4T-AL LT1-MS6W4T-AR LT1-MS6W6T-AL LT1-MS6W6T-AR LT1-MS7W5T-AL LT1-MS7W5T-AR

Left Right Left Right Left Right Left Right Left Right Left Right

Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

COMFORT-TEK LT1-RF4W3T LT1-RF5W3T LT1-RF5W4T LT1-RF6W4T LT1-RF6W6T LT1-RF7W5T

Left Right Left Right Left Right Left Right Left Right Left Right

Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

STRETCH-AIR LT1-RS4W3T LT1-RS5W3T LT1-RS5W4T LT1-RS6W4T LT1-RS6W6T LT1-RS7W5T

Left Right Left Right Left Right Left Right Left Right Left Right

Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

COMFORT-TEK LT1-RF4W3T-AL LT1-RF4W3T-AR LT1-RF5W3T-AL LT1-RF5W3T-AR LT1-RF5W4T-AL LT1-RF5W4T-AR LT1-RF6W4T-AL LT1-RF6W4T-AR LT1-RF6W6T-AL LT1-RF6W6T-AR LT1-RF7W5T-AL LT1-RF7W5T-AR

Left Right Left Right Left Right Left Right Left Right Left Right

Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

STRETCH-AIR LT1-RS4W3T-AL LT1-RS4W3T-AR LT1-RS5W3T-AL LT1-RS5W3T-AR LT1-RS5W4T-AL LT1-RS5W4T-AR LT1-RS6W4T-AL LT1-RS6W4T-AR LT1-RS6W6T-AL LT1-RS6W6T-AR LT1-RS7W5T-AL LT1-RS7W5T-AR

Left Right Left Right Left Right Left Right Left Right Left Right

Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

Page 3: VISCO BACK ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Visco-Back.pdf · visco-back® order form patient reference: page 3 of 4 5

VISCO-BACK® ORDER FORM Patient Reference: PAGE 3 of 4

BODILINK HEAD SUPPORT & HARDWARE5 Optional

COMFORT-TEK FOR FLUID PROTECTION & AN EASILY CLEANED

SURFACE.

FOR AIR TRANSMISSION & HEAT DISSIPATION.

STRETCH-AIR

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

L

L

L

L

L

W

W

5.2 PAD COVER MATERIAL

GlideWear® (GLIDEWEAR)

Comfort-Tek (COMFORT-TEK)

Stretch-Air (STRETCH-AIR)

Length (L) refers to the actual size dimension of the support from bottom to top edge.

HEAD SUPPORT PAD STYLEHCPCS CODING: E0955 MSRP $230.00

5.1

Pad Firmness

6W x 3½LSoft BL-HSP1-6W3L

Extra Soft BL-HSP2-6W3L

8W x 4LSoft BL-HSP1-8W4L

Extra Soft BL-HSP2-8W4L

10W x 5Lwith adjustable wings

Soft BL-HSP1-10W5L

Extra Soft BL-HSP2-10W5L

14W x 5Lwith adjustable wings

Soft BL-HSP1-14W5L

Extra Soft BL-HSP2-14W5L

18W x 5Lwith adjustable wings

Soft BL-HSP1-18W5L

Extra Soft BL-HSP2-18W5L

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EXTRA LINKSMSRP $35.00/link

LATERAL TRUNK SUPPORT & HARDWARE4 OptionalContinued

PROTECTIVE COVER (OPTIONAL)4.2

A) B)

4.3

RIGIDHCPCS Code: E0956

MSRP $125.00/bracket

SWING AWAYHCPCS Code: E1028

MSRP $263.00/ea

PROTECTIVE LATERAL HARDWARE COVER

MSRP $19.00/ea

Select a set of hardware below (Section A). Extra links (Section B) may be selected to add 1” of additional depth and adjustability.

CLOSED OPEN

3” 3”1”

EXTRA LINK

LATERAL TRUNK SUPPORT HARDWARE

LTL-SF LTR-SF LTL-RF LTR-RF LEFT LT1-LINK RIGHT LT1-LINK LT1-PROTECT2

Left Right Left Right 1 Extra Link 1 Extra Link Left Right

Extra Left Extra Right Extra Left Extra Right 2 Extra Links 2 Extra Links Extra Left Extra Right

3 Extra Links 3 Extra Links

4 Extra Links 4 Extra Links

Both hardware styles in Section A are width adjustable. Cover wraps around hardware and closes with hook and loop attachment.

Page 4: VISCO BACK ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Visco-Back.pdf · visco-back® order form patient reference: page 3 of 4 5

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VISCO-BACK® ORDER FORM Patient Reference: PAGE 4 of 4

BODILINK HEAD SUPPORT & HARDWARE5 Optional

Extra Link

Extra Spacer Plate

¼”

5.3 HEAD SUPPORT HARDWAREHCPCS CODING: E1028

MSRP $221.00/ea. MSRP $35.00/extra link or spacer each

Removable Hardware (BL-HSH-FX)

Extra Link (BL-HSH-LINK)

Extra Spacer Plate (BL-HSH-SPCR)

3 ¼”

Continued

SUBMIT BY EMAIL