Surgical Engineering Queensland. Co. Pty. Ltd. (Since 1970)

Manufacturers of Ultra-Light
Wheelchairs with custom made
seating. S/S bath chairs and
hand controls for disabled drivers.

 
Surgical Engineering
218 Holmes Street
Brighton, Qld
Australia, 4017
Ph: (07) 3869 1919  Int +61738691919
Fax: as above
Email : mike@sureng.com.au
ABN: 84 010 941 590

Prescription Form K.I.S MK III Wheelchair and Tilt in Space
Transit and Self-Propelling - for Postural Mods.

Client Name: Therapist Name:
Address: Therapist Phone:
Phone: Date Ordered:
Email :    
Ordered By: Financed By:
SEAT DEPTH   FRONT WHEELS  
410mm (Small) 125 x 25 (5x1) solid
460mm (Medium) 150 x 25 (6x1) solid
510mm (Large) 150 x 32(6x1¼) mpc
Other :   175 x 25 (7x1) solid
  200 x 25 (8x1¼) mpc  
    Pneumatics  
SEAT WIDTH   150 X 32 (6x1¼)
340mm 200 x 32 (8x1¼)
360mm 200 x 50 (8x2)
380mm REAR WHEELS:  
400mm 305mm (12")
420mm 451mm (20")
440mm 489mm (22")
460mm 540mm (24")
480mm REAR WHEEL TYPE:  
500mm Pneumatic
Other:   MCP
 
FRAME COLOUR: PUSH HANDLES
Height 920mm
  Other (mm)
 
TYPE OF WHEELCHAIR
Transit
Folding
Rigid
Self-propelled
Growing
Fold Down Back

1. Seat to back angle
( 95 degrees standard)		 degrees
2. Seat Tilt
(3 degrees standard)		 degrees
3. Footplate angle
(5 degrees dorsiflexed or
parallel to seat standard)		 degrees
LOWER LEG LENGTH
(seat bar to footplate)		 mm
(Swinging detachable leg-rests standard on the MKIII only)
  Notes:

: