Rehab Solutions Quote Request Form

Name*

Company Name

Phone Number

E-mail*

example@example.com

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 a standard 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 Chin Control.

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

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

What type of electronics is the chair equipped with?*

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?*

Standard Chin Control for R-net Electronics - 37905Standard Chin Control for Q-Logic Electronics - 37903Chin Control w/MicroGuide - 37880Chin Control w/MicroPilot - 37881

Would you like to include the Spring Loaded Silicone Ball?*

Yes - 5/8" Size Ball - 36090Yes - 7/8" Size Ball -36091No

The Chin Kit is made up of two 'whiskers' - one side is a switch for On/Off, the other is a switch for mode. Also included is a foam ball for interfacing with the chin drive control.

Would you like to include the Chin Kit - 37899?*

YesNo

How Many Sockets will you need?*

One - 30200; 30411Two - 30200 (x2); 30410Three - 30200 (x3); 30410

Where will you mount the sockets?*

FrontSideRear

Front Socket Bracket*

Flip Down - 30301
Angle Adjustable, Fold Down Front Socket Bracket

Stealth Angle Adjustable - 30309
Angle Adjustable, Fixed Front/Side Socket Bracket. 5.25"

Fixed Flat - 30355
Fixed 1 piece Front/Side Socket Bracket, Flat. 5.70"

Fixed 10° Bend - 30354
Fixed, 1 piece Front/Side Socket Bracket with a 10 degree bend. 5.70"

Your front socket requires you to physically mount a socket to the chair. An Evaluation Plate allows you to quickly and easily setup a front socket installation without any modifications to the seatbase.

Would you like an Evaluation Plate?*

Yes - 30366No

Side Socket Bracket*

Stealth Angle Adjustable - 30311
Angle Adjustable, Fixed Front/Side Socket Bracket. 8.25"

Fixed Flat - 30355
Fixed 1 piece Front/Side Socket Bracket, Flat. 5.70"

Fixed 10° Bend - 30354
Fixed, 1 piece Front/Side Socket Bracket with a 10 degree bend. 5.70"

Rear Socket Bracket*

Stealth Angle Adjustable w/
Extension Harness - 30386
Attendant 12" Fixed-Adjustable bracket for mounting a socket to the rear of a chair

Tubular Attendant Socket Bracket w/ Extension Harness - 30378
Attendant socket bracket tube for use with a square rear accessory tube

Ship the controls preassembled on a Pride Powerchair?*

YesNo

Please order the powerchair from Pride/Quantum and request for it to be shipped 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