Order form – Zebra Order number: Order Date:Company name / Name and surname Bill adress:* Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryE-mail:*Phone* Area Code - Phone Number Click if:shipping adress is the same as bill adressShip to: Shipment adress: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountryContact: Area Code - Phone Number Ship product:*AssembledDissasembledProduct size / Upholstery colours:*size 3 / SeaStandard EquipmentFrame with castors and brakesSeparate adjustable foot rest with footers and feet stabilizing beltsSeatSeat cushionAdjustable abduction blockBackrestBackrest cushionChest supportsPelvic belt ('Hold & Pull' system)4 points safety vest ('Hold & Pull' system) (2)Adjustable HexagonPro™ HeadrestElbow supportTrayGas springInnovative quadric mechanismBreathable upholstery ATMO™ – size 3 SEA. Accessories:Safety:ZBI_015 TANGO Wheel (75 mm) (A)ZBI_015 TANGO Wheel (75 mm) (I)ZBI_016 TANGO Wheel (125 mm) (A)ZBI_016 TANGO Wheel (125 mm) (I)ZBI_020 TANGO Wheel (100 mm) (A)ZBI_020 TANGO Wheel (100 mm) (I)Positioning:ZBI_101 Thigh abduction beltsZBI_102 Head supporting belt for HexagonPro™ Headrest ZBI_102 Head supporting belt for VisoPro™ HeadrestZBI_103 3D foot adjustment (U)ZBI_103 3D foot adjustment (I)ZBI_106 Lower limbs supporting cushionZBI_109 Independently adjustable side supports (I)ZBI_110 Knee support (instead of abduction block)ZBI_114 H Harness (A) (2)ZBI_114 H Harness (I) (2)ZBI_123 Adjustable extended headrest (I)ZBI_125 6 points safety vest S (I) (2) ZBI_125 6 points safety vest S (A) (2) ZBI_125 6 points safety vest M (I) (2) ZBI_125 6 points safety vest M (A) (2) ZBI_125 6 points safety vest L (I) (2) ZBI_125 6 points safety vest L (A) (2) ZBI_125 6 points safety vest XL (I) (2) ZBI_125 6 points safety vest XL (A) (2) ZBI_126 Trunk beltZBI_161/1 Foot and ankle stabilizing sandals(EUR: 21 – 24, CM: 13 – 15 cm; UK: 4,5 – 7, IN: 5,1 – 5,9 in)ZBI_161/2 Foot and ankle stabilizing sandals(EUR: 25 – 27, CM: 15 – 17 cm; UK: 7,5 – 9,5, IN: 5,9 – 6,7 in)ZBI_161/3 Foot and ankle stabilizing sandals(EUR: 27 – 31, CM: 17 – 19,5 cm; UK: 9 – 12, IN: 6,7 – 7,7 in)ZBI_161/4 Foot and ankle stabilizing sandals(EUR: 31 – 35, CM: 19,5 – 22,4 cm; UK: 12 – 2,5, IN: 6,7 – 8,8 in)ZBI_162/1 Dynamic ankle stabilizers (FP-22) (size XS, perimeter of the ankle CM: 4 – 17 cm; IN: 6 – 7 in)ZBI_162/2 Dynamic ankle stabilizers (FP-22) (size S, perimeter of the ankle CM: 16,5 – 20 cm; IN: 6 – 8 in)ZBI_162/3 Dynamic ankle stabilizers (FP-22) (size M, perimeter of the ankle CM: 19 cm – 23,5 cm; IN: 7 – 9 in)ZBI_162/4 Dynamic ankle stabilizers (FP-22) (size L, perimeter of the ankle CM: 23 cm – 28 cm; IN: 9 – 11 in)ZBI_162/5 Dynamic ankle stabilizers (FP-22) (size XL, perimeter of the ankle CM: 26,5 cm – 33 cm; IN: 10 – 13 in)ZBI_168 VisoPro™ HeadrestComfort:ZBI_431/1 Push handle, height - 1 cm from the backrest ZBI_431/2 Push handle, height - 19 cm from the backrest ZBI_431/3 Push handle, height - 31 cm from the backrest **ZBI_448/1 Self-leveling tray size 1**ZBI_448/2 Self-leveling tray size 2**ZBI_448/3 Self-leveling tray size 3**ZBI_448/4 Self-leveling tray size 4**ZBI_448/5 Self-leveling tray size 5*ZBI_453 Seat cushion with bolsterStorage:ZBI_507 Oxygen tank holder * IT IS NOT POSSIBLE TO USE THE ADJUSTABLE ABDUCTION BLOCK WHILE USING THE SEAT CUSHION WITH BOLSTER.** CUSTOM-MADE. LEAD TIME ca. 30 DAYS(U) THE MAXIMUM HEIGHT OF THE USER SHOULD BE REDUCED BY 6 CM. SEE SIZE TABLE(1) SIZE 3 AND OPTIONAL EQUIPMENT ARE CUSTOM-MADE. LEAD TIME ca. 30 DAYS.(2) H HARNESS, 4 POINTS AND 6 POINTS SAFETY VESTS SHOULD BE USED WITH ABDUCTION BLOCK OR THIGH ABDUCTION BELTS _101.Message to us:SubmitReset
