Custom Seat Order Form

Please complete all fields that apply. You can printout the Custom Seat Diagram as a reference when filling in the seat specifications below

Order Date:
Name:
Full Mailing Address:
Phone:
Email:
Sales Person:
W/C Manufacturer:
W/C Model
PO#:
Chair Size: Outside of tube to outside of tube
Color of Insert:

Seat
A- Seat Depth:
B- Seat Width:
C- Hip Width:

Laterals
F- Trunk Width:
G- Seat to top of lateral:

Headrest
L1 Pad Height:
Pad Width:
L2 Pad Height:
Pad Width:
L3 Pad Height:
Pad Width:

Laptray
Cutout Width:
Depth:

Footrest
Type:
Seat to bottom of heel:

Back
D-Seat to shoulder:
E-Seat to top of head:

Abductor
H -Height:
I-Width (Front):
J-Width (Rear):
Length:

Hip Guides
M-Pad height:
N-Pad length:
Standard Pad Size:
Length - Seat Length:
Height 4" above Seat:
Comments or Special Instructions
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Seat