Pride Mobility Products Corporation Account Number: Provider Name: Contact: Phone: Fax: Date: PO#: Marked For: Ship To: Address: City: State: Zip: Terms: Freight: Taken By: Milford Person Lift Order Form / Price List Milford Lift - Vehicle & Total oRight Hand Milford oLeft Hand Milford MSRP $4,080 $4,080 User Information - Vehicle Information Milford Lift - Travel oMilford Only oMilford Smart Base MSRP $3,880 $2,270 Vehicle Make:___________Model:__________Year:______ *Fitting Kit Included in both right and left* *Battery Pack Included* Milford - Home oMilford Only oBattery Pack MSRP $3,880 $275 Spreader Bars oStandard oSmall oExtra Wide oNo Selection MSRP $295 $295 $295 NC *Refer to Chart C on page 2 Extension Arms oStraight Extension Arm MSRP $295 oRight Hand Extension Arm oRight Hand Dropped 2” Extension Arm oRight Hand Dropped 4” Extension Arm oRight Hand Dropped 6” Extension Arm oRight Hand Dropped 8” Extension Arm oRight Hand Dropped 10” Extension Arm oRight Hand Dropped 12” Extension Arm $295 $295 $295 $295 $295 $295 $295 oLeft Hand Extension Arm oLeft Hand Dropped 2” Extension Arm oLeft Hand Dropped 4” Extension Arm oLeft Hand Dropped 6” Extension Arm oLeft Hand Dropped 8” Extension Arm oLeft Hand Dropped 10” Extension Arm oLeft Hand Dropped 12” Extension Arm $295 $295 $295 $295 $295 $295 $295 oNo Extension Arm NC Patient Height:___________Patient Weight:__________ Sling Options oExtra Small Standard Sling oSmall Standard Sling oMedium Standard Sling oLarge Standard Sling oExtra Large Standard Sling MSRP $325 $325 $325 $325 $325 oSmall Double Amputee Sling oMedium Double Amputee Sling oLarge Double Amputee Sling $395 $395 $395 oMedium Fleece Lined Sling oLarge Fleece Lined Sling $525 $525 oSmall Net Sling oMedium Net Sling oLarge Net Sling $250 $250 $250 oNo Selection NC *Refer to Charts A and B on page 2 Accessories oB Pillar Fitting Kit oSmall Spreader Bar Cover oStandard Spreader Bar Cover oBattery Pack & Charger oCill Bracket oWall Bracket oWall Bracket Straight 3” Spacer oWall Bracket Straight 6” Spacer oWall Bracket Straight 9” Spacer oWall Bracket Straight 12” Spacer MSRP $250 $75 $75 $275 $225 $595 $250 $250 $250 $325 *B Pillar is only available right side *The amount of drop of the Extension Arm is calculated by subtracting the STF of the Mobility Device from the STF of the vehicle and dividing the difference in half. Revised: January 31, 2014 Page 1 Chart A Milford Lift Sling Sizing Chart Weight 0-80 lbs. 90 lbs. 100 lbs. 110 lbs. 120 lbs. 130 lbs. 140 lbs. 150 lbs. 160 lbs. 170 lbs. 180 lbs. 190 lbs. 200 lbs. 210 lbs. 220 lbs. 230 lbs. 240 lbs. 250 lbs. 260 lbs. 270 lbs. 280 lbs. 290 lbs. 300 lbs. 310 lbs. 320 lbs. 320 lbs. Chart B Sling Size Waist Sling Size 0-4’10” 0-4’10” 0-4’10” 4’10” - 5’4” 4’10” - 5’4” 4’10” - 5’4” 5’3” - 5’7” 5’3” - 5’7” 5’3” - 5’7” 5’6” - 6’4” 5’6” - 6’4” 5’6” - 6’4” 5’6” - 6’4” 5’6” - 6’4” 5’6” - 6’4” 5’6” - 6’4” 5’6” - 6’4” 5’9” - above 5’9” - above 5’9” - above 5’9” - above 5’9” - above 5’9” - above 5’9” - above 5’9” - above 5’9” - above XSM XSM XSM/S SM SM SM/MED MED MED MED/LRG MED/LRG MED/LRG LRG LRG LRG LRG LRG/XLRG LRG/XLRG LRG/XLRG LRG/XLRG XLRG XLRG XLRG XLRG XLRG XLRG XLRG X-Small Small Medium Large X-Large 0-18” 18-22” 22-30” 30-44” 44”-above Chart C Spreader Bar Size Waist Height Small Under 26” Revised: January 31, 2014 Standard 27-42” X-Large Over 42” Page 2
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