Prosthetic Ordering Guide

Complete the questions below and fax to 1-630-672-7778 or email to [email protected].

Patient Height ______(5’3” and under short leveling feet, 5’4” - 6’0” standard leveling feet, 6’1” - 6’3” long leveling feet, 6’4” or greater height extenders)

Patient Weight ______(Under 265 pounds recommend LS300 / Greater than 265 pounds recommend Independence IV)

Will the patient use the product by the bedside? Y | N (If yes, consider locking caster accessory)

Does the patient have an outlet in the ? Y | N (If no, consider battery kit option)

Does patient live in an area prone to power outages? Y | N (If yes, recommend battery back-up kit)

Will the product be moved between the bedroom and the bedside frequently? Y | N (If yes, consider locking caster accessory)

Does the patient’s medical condition limit the use of their fingers? Y | N (If yes, consider big button hand pendant and/or foot switch)

Does the patient have difficulty sitting on hard surfaces? Y | N (If yes, recommend soft padded seat)

Does the patient have difficulty performing the hygienic cleaning after ? Y | N (If yes, recommend electric washing )

On GSA Item Number Item Description Item Description 2 U/M QTY GSA Price TOTALS Contract  LS300-X-101 LifSeat 300 Independence II Unit Only LS300 Independence II unit AC Powered with No EA 1 $1,099.00 $ splash guard and commode bucket

 LS300-AP-110-G LiftSeat 300 Pro Package LS300 Independence II unit with battery kit, spare Yes EA 1 $1,499.00 $ battery, commode, and splash guard

 LS400-X-100 LiftSeat Independence IV - Unit Only Independence IV unit AC Powered only with splash No EA 1 $1,499.00 $ guard and commode bucket

 LS400-X-100-G LiftSeat Independence IV Pro Package Independence IV unit with battery kit, spare battery, No EA 1 $1,899.00 $ commode, and splash guard

 LS-BRN-1000 Brondell Swash 1400 Electric Washing Bidet No EA 1 $699.00 $ Optional Accessories  LS000-CB-100 Reusable Drop-in Commode Bucket Converts over the toilet into bedside commode No EA 1 $24.00 $  LS300-LF-37 Standard Leveling Feet For individuals 5'4" to 6'0" tall No EA 1 N/C $  LS300-LF-38 Short Leveling Feet For individuals 5'3" or below No SET 1 $28.00 $  LS300-LF-39 Long Leveling Feet For individuals 6'1" to 6’3” No SET 1 $28.00 $  LS300-I-EXT Height Extenders For indivduals 6'4” or greater No SET 1 $74.00 $  LS300-HH-500 Big Button Hand Pendant For patients with limited hand control No EA 1 $135.00 $  LS300-J90035 Foot Switch For patients with limited hand control No EA 1 $205.00 $  LS900-TS-100 Soft Padded Toilet Seat w/ lid Soft Toilet seat with lid No EA 1 $45.00 $  LS900-TS-101 Soft Padded Toilet Seat w/o lid Soft Toilet seat without lid No EA 1 $45.00 $  LS900-BK-101 Battery Kit Includes: Battery, Battery Charger, Wall Mounting No EA 1 $300.00 $ Bracket w/ Extension Cord

 LS300-BA-200 Spare Battery (Battery back up) Battery Only (can be purchased as a backup No EA 1 $115.00 $ battery)

 LS900-I2W-100 Locking Medical Grade Caster For individuals 5'10” or greater No SET 1 $96.00 $  LS900-WK-100 Lowering Wheel Kit For individuals 5'9” or below No SET 1 $150.00 $  LS900-BR-100 Back Rest Option Recommended for use in bedside configuration No EA 1 $135.00 $ (cannot use with bidet)

 LS900-RHB-100 Retractable Handle Bar (each) Retractable Arm to allow for side transfer No EA 1 $125.00 $  LS900-INST-HOME Home Assembly and Installation of Liftseat Assembly and Installation of Toilet Lift - Pricing No TBD $ and / or Bidet varies on distance from major city and market labor costs

 I2/I4 Shipping estimate Shipping Cost of Independence II Shipping Charges could vary according to total or- No $85.00 $ der including accessories and location of shipment NOTES: TOTAL $

TO ORDER OR FOR QUOTATION: NAME Fax or email this form EMAIL ADDRESS FAX 630 672-7778 EMAIL [email protected] PHONE PHONE 1-877-665-4381 FAX GSA Contract Number: GS-07F-0453V EIN: 87-0766923 DUNS: 85-996-0481 COMMON CONFIGURATIONS

Independence II Independence II Independence IV with electric wash bidet with locking wheels with electric wash bidet and raised seating height extenders

ACCESSORIES

Locking Wheels Raised Seating Hand Pendant Options Foot Pedal Option Backrest and/or Height Extenders Retractable Handle Bars

Back up battery Soft Toilet Seat Drop In Bucket Electric Washing Bidet Or battery power only kit For Bedside Commode Use

Installation Options for LiftSeat Toilet Lift Installation Options for Electric Wash Bidet • Prosthetics contracts with a local DME • Recommended - Prosthetics orders electrical GFI outlet (LiftSeat can help with installation instructions) to be installed by toilet • LiftSeat conducts the assembly and installation = $450.00 • Customer utilizes extension cord into GFI outlet in bathroom • Prosthetics contracts a local DME or Plumber to install bidet • LiftSeat contracts to do electrical and installation = Price to be determined