Surgical Engineering Queensland. Co. Pty. Ltd.

General Prescription Form
Manufacturers of Light-Weight Wheelchairs, Hand controls, Sports Wheelchairs Since 1970.

Surgical Engineering
218 Holmes Street
Brighton, Qld
Australia, 4017
Ph: (07) 3869 1919  
Fax: (07) 3869 1919  
Int: 61 73869 1919
ABN: 84 010 941 590
Client Name: Therapist Name:
Address: Therapist Phone:
Phone: Date Ordered:
Email : . .
Ordered By: Financed By:

TYPE OF WHEELCHAIR
KIS MK1
KIS MK11
KIDZ Chair
Getabout

Rigid     

 Grow  Fold      Tuck Front

Fold Down Back 

Seat Width

  cm/in
Leg Length

cm/in
Seat Depth

cm/in
Back Height

cm/in
BRAKES
Long Short Toggle
High Mount Low Mount Scissor
REAR WHEELS (All quick release)
20 22 24 26
1"            
1 3/8 1.75 pneumatic m.c.p
FRONT WHEELS
5 x 1 solid 6 x 1 solid
6 x 1 m.c.p 8 x 2 m.c.p
rollerblade 8 x 1 pneumatic
8 x 1 m.c.p. 8 x 2 pneumatic
ARMRESTS
Standard Desk
Adjustable Height  cm/in
SEAT HEIGHT
Front
cm/in
Rear Height or
angle

cm/in
FRAME COLOUR
FOOTPLATES
Fixed Split
Single Swinging
Detachable Heavy Duty
PUSH RIMS (All S/S)
Capstan Rubberised
UPHOLSTERY
Cordura Black Mesh Black
Vinyl Black    
F.O.P. Seat Flat Wedge
F.O.P. Back Flat Curved
POLYCARBONATE TRAY
Fitting onto armrests own fittings
height cm/in  
HIP PROTECTORS
Cloth Cloth with aluminium strip
Polycarbonate
 
Extras and Comments: