Surgical Engineering Queensland. Co. Pty. Ltd.

Prescription Form for Tilt-in-Space Shower Chair.

  • Rear Wheels M.C.P. tyres.
  • S/S axles.
  • S/S Roller bearings.
  • S/S frame powder coated to the colour of your choice.
  • Any choice of seat.
  • Front Castors: S/S with 125mm (5) wheel.
  • Back and seat are hand made.
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:
Standard Back 200mm deep               Special: mm deep
Standard Seat 440mm square x 62mm thick. (50mm Foam plus 12mm board) 
Seat:  Pressure Relief Special   75mm thick. (38mm Firm / 25mm Soft foam / 12mm board)
Seat: Open front   Closed front  Special size
Seat : R/S Open   L/S Open   Rear  Bite:    R/S   L/S
Standard Frame width 440mm.           Special:mm
Folding Frame:  Yes    No  
Arm Rests: Yes   No  
Flipup
   
Removable

Padded
Attendant Prop: (4 Castor)
(2 Castor with brake)
Rear Wheel Size :   24     22    20   Pan and Rack:  Yes  No
Hand rims (optional):  Yes    No Calf Strap: Yes  No     Padded: Yes  No
Leg Rests: Swing/Detach   Yes    No Chest Strap: Yes  No   Padded: Yes  No

Leg length:  mm Back height:   mm Seat height front: mm
Handle ht:    mm Frame colour: Seat height rear:  mm

Special
requirements,
Comments: