Voyager Plus Folding Wheelchair Order Form

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Hello there, please try to fill this form with as much detail as possible. There is a note section at the end of the questionaire to add any additional information.

For feedback, please email us at csr@powerplusmobility.com or call us at Telephone (905)-614-0333 Toll Free 1-(855)-614-0333.

Our website: https://powerplusmobility.com

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Name* This field is required

First Name

Last Name

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A little about your store:* Please enter the name of your storePlease enter the name of your store

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PO Number:* This field is required Please note that a Purchase Order Number is required to be processed as an Order. This is only a quote request. You may reply to the Quote Confirmation Email with a P.O Number to start the order process.

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Frame colour* This field is required

VGPB Frame - Black

VGPS Frame - Silver

VGPC Frame - Custom

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Custom frame colour. Please enter the colour below:* This field is requiredType custom colour information

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Client weight:* This field is required

VGPWA Up to 250Lbs

VGPWAMF Exceeds 250Lbs

VGPWAMG Exceeds 350Lbs

VGPWAMH Exceeds 400Lbs (Max 600Lbs)

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Seat width:* This field is required

VGPSW14 Seat Width 14"

VGPSW15 Seat Width 15"

VGPSW16 Seat Width 16"

VGPSW17 Seat Width 17"

VGPSW18 Seat Width 18"

VGPSW19 Seat Width 19"

VGPSW20 Seat Width 20"

VGPSWC Custom Seat Width

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If custom seat width. please enter the seat width below:* This field is requiredType custom width information

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Seat depth:* This field is required

VGPSD16 Seat Depth 14"

VGPSD16 Seat Depth 15"

VGPSD16 Seat Depth 16"

VGPSD17 Seat Depth 17"

VGPSD18 Seat Depth 18"

VGPSD19 Seat Depth 19"

VGPSD20 Seat Depth 20"

VGPSDC Custom Seat Depth

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If custom seat depth. Please enter the seat depth below:* This field is required

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Back Height* This field is required

VGPBH15 Back Height 15"

VGPBH16 Back Height 16"

VGPBH17 Back Height 17"

VGPBH18 Back Height 18"

VGPBH19 Back Height 19"

VGPBH20 Back Height 20"

VGPBH21 Back Height 21"

VGPBHC Back Height Custom

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If custom back height. Please enter custom back height below: * This field is required

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Foot rest and foot plates:* This field is requiredPlease note we do not offer the Pin Style with folding wheelchairs. They are only available with Pivot Style.

VGPF6A 60 Degree Hanger

VGPF7A 70 Degree Hanger

VGPF8A 80 Degree Hanger

VGPEA Elevating Legrest

VGPAL Articulating Legrest

VGPEB Elevating Legrest System

VGPPPL Plastic

VGPPXL Extra Large

VGPPAF Angle Adjustable Footplates

VGP1FB One Piece Foot Board

VGPNLS Nylon Leg Strap Padded

VGPNLSC Nylon Leg Strap Custom

VGPCSL Contracture Sling Standard

VGPCSLM Contracture Sling M-Style

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Size of custom nylon leg strap?* This field is required

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Arm rests:* This field is required

VGPTA T-Arm Ht. Adj./ Removable (Standard 10 - 14 inches)

VGPFA Flip Back Ht. Adj./ Removable (Standard 10 - 14 inches)

VGPTAS T-Arm Ht. Adj./ Removable (Short 7 - 11 inches)

VGPFAS Flip Back Ht. Adj./ Removable (Short 7 - 11 inches)

VGPGWAPF Gel Waterfall Arm Pads

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Rear wheels:* This field is required

VGPRWT0 20” Solid Treaded Tire

VGPRWT2 22” Solid Treaded Tire

VGPRWT4 24” Solid Treaded Tire

VGPRWA2 22” Air Tire

VGPRWA4 24” Air Tire

VGPAQR Axles – Quick Release

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Seat to floor specifications (STF):* This field is required
STF = SL 12.25, R.Wheel = 20, Caster = 5, Fork = XL SHORT

STF = SL 13.00, R.Wheel = 20, Caster = 5, Fork = XL SHORT

STF = LL 13.75, R.Wheel = 20, Caster = 5, Fork = XL SHORT

STF = L 14.50, R.Wheel = 20, Caster = 6, Fork = SHORT

STF = L 14.50, R.Wheel = 22, Caster = 5, Fork = SHORT

STF = L14.50, R.Wheel = 22, Caster = 6, Fork = SHORT

STF = LH 15.25, R.Wheel = 20, Caster = 5, Fork = SHORT/LONG

STF = LH 15.25, R.Wheel = 20, Caster = 6, Fork = SHORT/LONG

STF = LH 15.25, R.Wheel = 22”, Caster = 5”, Fork = SHORT/LONG

STF = LH 15.25, R.Wheel = 22, Caster = 6, Fork = SHORT/LONG

STF = SH 16.00”, R.Wheel = 22, Caster = 6, Fork = LONG

STF = MH 16.75”, R.Wheel = 22”, Caster = 6”, Fork = LONG

STF = H 17.50, R.Wheel = 22, Caster = 6, Fork = LONG

STF = H 17.50, R.Wheel = 22, Caster = 8, Fork = LONG

STF = H 17.50, R.Wheel = 22, Caster = 6, Fork = LONG

STF = H 17.50, R.Wheel = 24, Caster = 8, Fork = LONG

STF = A 18.25, R.Wheel = 24, Caster = 8, Fork = LONG
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Caster size:* This field is required

VGPFC1A 5” X 1.25” Caster

VGPFC1B 6” X 1.25” Caster

VGPFC1C 8” X 1.25” Caster

VGPFC2A 5” X 1.75” Caster (Soft Roll)

VGPFC2B 6” X 1.75” Caster

VGPFC2C 8” X 1.75” Caster

VGPFC4B 6” X 2 Caster (Steel Fork)

VGPFC4C 8” X 2 Caster (Steel Fork)

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Wheel lock options:* This field is required

VGPALPH Aluminium Push To Lock

VGPALPL Aluminium Pull To Lock

VGPSTPH Steel Push To Lock

VGPSTPL Steel Pull To Lock

VGPBRXC 4” Brake Extension

VGPBRXA 6” Brake Extension

VGPBRXB 9” Brake Extension

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Seating - backs:* This field is requiredNote: Please refer to the seating booklet for custom sizes

VGPBK01 RELAX Gentle Fit Back

VGPBK02 RELAX Full Fit Back

VGPBK03 RELAX Snug Fit Back

VGPBK04 RELAX Form Fit Back No Laterals

VGPBK06 RELAX Form Fit Back Gentle Laterals

VGPBK07 RELAX Form Fit Back Full Laterals

VGPBK05 RELAX Form Fit Back Snug Laterals

VGPBK10 RELAX Spiral Fit Back Gentle Laterals

VGPBK09 RELAX Spiral Fit Back Snug Laterals

VGPBK11 RELAX Spiral Fit Back Full Laterals

VGPTAB RELAX Tension Back Upto 18”

VGPTAB+ RELAX Tension Back Over 18”

VGPBGL1 Full Overlay Gel (2 Pieces)

VGPBGL2 Gel Center Vertebrae

VGPBGL3 Gel Left Lateral

VGPBGL4 Gel Right Lateral

VGPBK12 Custom Width

VGPBK13 Custom Height

No Back

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Enter back width and height:* This field is required

Width

Height

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Enter custom width below:* This field is requiredCustom width

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Enter custom height below:* This field is requiredCustom height

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Seating - cushions:* This field is requiredNote: Please refer to the seating booklet for custom sizes

VGPC01 RELAX Soft Cushion

VGPC02 RELAX Comfy Cushion

VGPC03 RELAX Firm Cushion

VGPC04 RELAX AIRFLOW Cushion

VGPCGL2 Full Overlay Gel

VGPCCL Contoured Leg Channel (Bolster) Std.

VGPCCLC Contoured Leg Channel (Bolster) Custom ( *Note: Please refer to the Seating Booklet for custom sizes)

VGPC00 Extra Cushion Cover

No Cushion

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Accessories:

VGPSBA Seat Belt (Auto Style)

VGPSBAP Seat Belt (Padded)

VGPSBA4P Seat Belt (4 Point Padded)

VGPTRA Full Padded Tray Locking

VGPTRB Full Padded Tray Slide On

VGPTRC Full Plastic Tray ABS Black or Clear

VGPTRD Half Padded Left Tray

VGPTRE Half Padded Right Tray

VGPTRF Half Left Tray ABS Black or Clear

VGPTRG Half Right Tray ABS Black or Clear

VGPTDFB Transport Tie Downs Front

VGPTDRB Transport Tie Downs Rear

VGPOXY Oxygen Tank Holder

VGPIVA Adjustable I V Pole

VGPCHPT-L Left Arm Trough Tray

VGPCHPT-R Right Arm Trough Tray

VGPLATB Lateral Bite out

VGPADD8 8" Adductor

VGPADD10 10" Adductor

VGPADD12 12" Adductor

VGPFRCH Padded Footplates

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Lap tray material:* This field is required

ABS Black

Clear

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Notes:* Please enter any other additional information or comments you may have for this quote below

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Sub total

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Your discount structure is based on the agreement with Power Plus MobilityPlease check with head office for a discount structure list

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Total MSRP:

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Enter email to receive a confirmation as well as a contact method if we needed more information:* This field is required

example@example.com

Confirm Email

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