Active Controls Rehab Solutions Quote

Name*

Company Name

Phone Number

Area CodePhone Number

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

What is the make and model of the powerchair you are fitting with Active Controls?

Other than Chin Control, Active Controls Rehab Solutions require an enhanced display to function. How do you plan to mount the display with the chair?

The display will be mounted on the drive control.I will mount the display to the drive control, but I will provide it myself.I plan to mount the display on the armrest, but I need the display included in my quote. (30470)I plan to use my existing armrest mounted enhanced display that I already have. (30470)I need a quote for a conventional Chin Control.

What type of electronics is the chair equipped with? (Needs Harnesses)*

What type of electronics is the chair equipped with?*

What type of electronics is the chair equipped with? (Selects Armrest Mounted Display)*

What control system will you be using? (For R-Net)*

JoyBar with Enhanced Display (Enhanced JoyBar) R-net Omni Display - 37602ReJoy MicroPilot (Switch-IT MicroPilot) R-net Omni Display - 37908ReJoy MicroGuide (Switch-IT MicroGuide) R-net Omni Display - 37926ReJoy Touch (Switch-IT Touch Drive 2) R-net Omni Display - 37909Active Tray with 4 Switch-IT Proximity Switches R-net Omni Display - 37914Active Tray with 5 Switch-IT Proximity Switches R-net Omni Display - 37906ReJoy With Stealth Mushroom Drive R-net Omni Display - 37907

What control system will you be using? (For Q-Logic)*

JoyBar with Enhanced Display (Enhanced JoyBar) Q-Logic Display - 37604ReJoy MicroPilot (Switch-IT MicroPilot) Q-Logic Display - 37922ReJoy MicroGuide (Switch-IT MicroGuide) Q-Logic Display - 37927ReJoy Touch (Switch-IT Touch Drive 2) Q-Logic Display - 37921Active Tray with 4 Switch-IT Proximity Switches Q-Logic Display - 37924Active Tray with 5 Switch-IT Proximity Switches Q-Logic Display - 37923ReJoy With Stealth Mushroom Drive Q-Logic Display - 37920

What control system will you be using? (For Q-Logic - Armrest Mounted Display)*

Enhanced JoyBar for Armrest Mounted Display No RAM Mount - 37605, 30470ReJoy MicroPilot (Switch-IT MicroPilot No RAM Mount - 37912ReJoy MicroGuide (Switch-IT MicroGuide) No RAM Mount - 37925ReJoy Touch (Switch-IT Touch Drive 2) No RAM Mount - 37911Active Tray with 4 Switch-IT Proximity Switches No RAM Mount - 37915Active Tray with 5 Switch-IT Proximity Switches No RAM Mount - 37913ReJoy With Stealth Mushroom Drive No RAM Mount - 37910

What control system will you be using? (For R-Net - Armrest Mounted Display)*

Enhanced JoyBar - 37605, 30470ReJoy MicroPilot (Switch-IT MicroPilot) - 37912ReJoy MicroGuide (Switch-IT MicroGuide) No RAM Mount - 37925ReJoy Touch (Switch-IT Touch Drive 2) No RAM Mount - 37911Active Tray with 4 Switch-IT Proximity Switches No RAM Mount - 37915Active Tray with 5 Switch-IT Proximity Switches No RAM Mount - 37913ReJoy With Stealth Mushroom Drive No RAM Mount - 37910

What control system will you be using? (No Display For Q-Logic)*

Enhanced JoyBar No Display Q-Logic Ready - 37601ReJoy MicroPilot (Switch-IT MicroPilot) No Display - 37912ReJoy MicroGuide (Switch-IT MicroGuide) No Display - 37925ReJoy Touch (Switch-IT Touch Drive 2) No Display - 37911Active Tray with 4 Switch-IT Proximity Switches No Display - 37915Active Tray with 5 Switch-IT Proximity Switches No Display - 37913ReJoy With Stealth Mushroom Drive No Display - 37910

What control system will you be using? (No Display For R-Net)*

Enhanced JoyBar No Display R-net Ready - 37601, 30404ReJoy MicroPilot (Switch-IT MicroPilot) No Display - 37912ReJoy MicroGuide (Switch-IT MicroGuide) No Display - 37925ReJoy Touch (Switch-IT Touch Drive 2) No Display - 37911Active Tray with 4 Switch-IT Proximity Switches No Display - 37915Active Tray with 5 Switch-IT Proximity Switches No Display - 37913ReJoy With Stealth Mushroom Drive No Display - 37910

What type of Chin Control do you want?*

Chin Control for R-net Electronics - 37905Chin Control for Q-Logic Electronics - 37903

How Many Sockets will you need?*

1 - 30200; 304112 - 30200 (x2); 304103 - 30200 (x3); 30410

Where will you mount the sockets?*

FrontSideRear

Front Socket Bracket*

Flip Down - 30301

Stealth Angle Adjustable - 30309

Fixed Flat - 30355

Fixed 10° Bend - 30354

Side Socket Bracket*

Stealth Angle Adjustable - 30311

Fixed Flat - 30355

Fixed 10° Bend - 30354

Rear Socket Bracket*

Stealth Angle Adjustable w/
Extension Harness - 30386

Tubular Attendant Socket Bracket w/ Extension Harness - 30378

For Pride/Quantum Power Chairs, you can have your base shipped to Active Controls for installtion of your selected drive control for a $95 installation fee. Would you like to include this in your quote as well?*

YesNo

I have / will order the powerchair from Pride Mobility Corp. and have specified the ship to:

Active Controls
597 Mantua Blvd.
Sewell, NJ 08080

I have an existing powerchair or I am going to order another manufacturer's powerchair for this quote.

Is the quote you are requesting for a Veteran / VAMC?

YesNo

Please Enter the Last Name and Last 4 Digits of the veteran's social for future identification.

Additional Comments