Chunc: Chunc 45 Prescription

Chunc 45 Prescription and Modification form

The following form may be used for requesting orders, quotations and modifications. No sections, apart from name and e.mail are mandatory.

Account information

Contact name:
Email address:
Client name:
Address:
Post code:
Telephone:
Fax:
Chair number:
Quote number:
Enquiry type:	Purchase order Free on loan Quote Purchase order
	Purchase order number:
Purchase method:	NHS Voucher Private Distributor/Dealer

NHS-only Invoicing

Shipping details

	Please tick if shipping name, address/postcode telephone and fax is the same as above
Name: (if different)
Address: (if different)
Post code: (if different)
Sales rep:
Date:
Buyer:
Telephone: (if different)
Fax: (if different)

Size and colour

Chunc 45 size:
Please note: The Chunc 45 includes standard armrests and legrests
Colour:

Seating options

Seat:
Please note: enhanced contour cushion can not be fitted with pommel
Backrest:
Please note: A sacral backrest is normally ordered with Knee blocks
PSIS:	PSIS insert : ASM 1741-2/4 Small for XS and S backrests, large for M and L backrests

Support options (all optional)

Further information about the options available may be found in the PDF document:
Options (HRS document number 1103-03-08)
Click here to download Adobe Acrobat Reader for free.

Headrest:

Thoracics left:		right:

Armrests:
Please note: the tray and/or rain cover can not be fitted with multiplace armrest

Thigh laterals left:		right:

Pommel:
Please note: pommel is not suitable for enhanced contour cushion

Knee blocks:
Please note: knee blocks are not suitable for enhanced contour cushion

Calf pads left:		right:

To request modifications to standard Chunc options, please refer to the Modification section below...

Other options (all optional)

Further information about the options available may be found in the PDF document:
Options (HRS document number 1103-03-08)
Click here to download Adobe Acrobat Reader for free.

Spare covers:		colour:
Please note: for part set, specify items in additional information section

Tray:
Please note: the tray cannot be fitted with a multiplane armrest

Raincover:	one size only : ASM 1566-1

Poncho:	one size only : ASM 1536

Running disk brakes:	one type only : ASM 1657-1
Please note: Not available with power assist

Power assist:	one type only : ASM 1726
Please note: Not available with running brakes and only available on 75kg model

Comm. aid mount:	one type only : ASM 1688

Spokeguards:
Please note: The spoke guards are fitted as standard on the 75kg models

Primary growth kits:
Please note: The seat and backrest must be ordered separately to the growth kit. Please tick the required check boxes on the Seating options.

To request modifications to standard Chunc options, please refer to the Modification section below...

Harness options (all optional)

Further information about the options available may be found in the PDF document:
Options (HRS document number 1103-03-08)
Click here to download Adobe Acrobat Reader for free.

To request modifications to standard Chunc options, please refer to the Modification section below...

Modification requirements

Seat modification

	Type:	basic
		contour
		ischial
		enhanced contour

	Size:	extra small
		small
		medium
		large

	Adjustments A:	mm more
	B:	mm more
Please note: Pommel will be mounted to the longest side of seat modifications. Also, if both sizes are increased by the same amount, consider using a larger standard seat.

Back modification

	Type:	basic
		supportive

	Size:	extra small
		small
		medium
		large

	Adjustments C:	mm greater or smaller
	For additional seat covers, please specify your requirements in the following section.

Modifications to standard Chunc options

Please describe any modifications that are required for the Chunc wheelchair and standard accessories in the box below:

Non-standard modifications

Large footplates

Foot box

Handle bar extension

Backrest mounted storage box

Backrest mounted suction equipment mount

Ventilator mounting tray

O2 cylinder mount

Submit form

Please check the information provided before submitting the form.

A copy will be e.mailed to the address provided for your future reference/records.