GrandMar Stability Belt Support Order Form

Date: _________PO #:_____________________Resale No:______________________ Contact: __________Phone:___________________Fax:_________________ Bill to: _____________________________Ship to:_____________________________ ___________________________________ ___________________________________ ___________________________________ __________________________________

What size chest strap?

For individual users, give chest circumference in inches. ___________
For multi-adjustable, designate Small (28”), Medium (28” to 36”), Large (36” to 44”), XL (44” to 52”)

2. What material will be used for the chest strap? Complete a or b.

4” loop- most commonly ordered. _______
2” webbing- recommended if chafe is not a concern. _______

3. How will the Torso Support open/close? Complete a, b, c, and d, (if applicable)

Closure I- hook and loop overlap, with D ring
Closure II- thread through and fold back, with D ring
Closure III- plastic quick-release buckle, _______ or,
additional $6.00 for auto buckle _______, or airline buckle _______

Note: Multi-adjustable- available in Closure I & 2

How will the webbing back strap attach? Complete a, b, or c.
-Buckle in back.

-Circumference of back. _______
-Width of back. _______

Attach with grommets- does not apply to recline systems.

-Width of chair._______
-Distance from screw to screw, across the front, following contour, including back cushion or laterals. _______

Attach to multi-mounts-recline system.

-Width of chair._______
-Distance from multi-mount attachment point, across the front, following contour, including back cushion or laterals. _______
Note: The Torso Support is not compatible with all recline systems. There must be a place to attach the webbing back strap that will allow the Torso Support to move with the wearer when reclining.

If the Torso Support is going on a wheelchair, please identify the make and model of the wheelchair.

Make:_____________________ Model:______________________