Surgical Engineering Queensland. Co. Pty. Ltd.


Prescription Form
K.I.S MK III Wheelchair
Tilt in Space
Transit and Self-Propelling
 for Postural Mods.
 
Surgical Engineering
218 Holmes Street
Brighton, Qld
Australia, 4017

Ph: (07) 3869 1919  
Fax: (07) 3869 1919  
Int: 61 73869 1919
ABN: 84 010 941 590
Client Name: Therapist Name:
Address: Therapist Phone:
Phone: Date Ordered:
Email :    
Ordered By: Financed By:
SEAT DEPTH   FRONT WHEELS  
410mm (Small) 25 x 25 solid
460mm (Medium) 6 x 1” solid
510mm (Large) 6 x 1 ¼” pneumatic
Other :   175 x 29 solid
  8 x 1 ¼” pneumatic
SEAT WIDTH   REAR WHEELS:  
360mm 20”
380mm 24”
400mm Pneumatic
420mm MCP
440mm PUSH HANDLES:  
460mm Height 920mm
480mm Other:  
LOWER LEG LENGTH
(seat bar to footplate)
mm   FRAME COLOUR:  
(Swinging detachable leg-rests standard on the MKIII only)  
TYPE OF WHEELCHAIR
Transit
Folding
Self-propelled
Growing

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

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