Leis Tech Chair Order Form

Please complete all fields that apply.

Order Date:
Name:
Full Mailing Address:
Phone:
e-Mail:

	Leis Tech non tilt positioning chair hi base
	LNLB01 - Leis Tech non tilt positioning chair lo base
	LTPC01 - Leis Tech tilt positioning chair hi base
	LTLB01 - Leis Tech tilt positioning chair lo base
	LTHA01 - Leis Tech height adjustable chair

Accessories
	LT2200 - 4 x 4 lateral trunk supports
	LT2500 - 4 X 8 adjustable hip supports
	LT3100 - Foam headblocks
	LT3102 - Adjustable winged headpads
	LT3108 - Flip away headrest panel
	LTCB01- Custom height, width or depth (specify)
	LLT910 - Slide on laptray
	LT4100 - Abductor
	LT9309 - Clear tray overlay
	LT9307 - Easel tray
	LT9306 - Protraction pads
	Colors Available: Teal, Peach & Blue

Measurements
Seat Depth
Hip Width
Back Height to Shoulder
Height Top of Head
Knee to Heel
Lateral Height
Trunk Width

Accessories