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ATP Evaluation
UniversalMed Supply
A Dusara Corp. Subsidiary
Technology Assessment for
Seating / Wheeled Mobility (ATP Evaluation)
ATP Evaluation - Supplementary Data
Patient's Name:
Patient's Weight:
Suggested Selection:
Base + Features
Power Tilt & Recline
Power Tilt
PWC
Tilt-In Space
Ultra-Lightweight
No Change
Change to
Power Tilt & Recline
Power Tilt
PWC
Tilt-In Space
Ultra-Lightweight
Cushion
General
Skin Protection
Positioning
Combination
General
Positioning
No Change
Change to
General
Skin Protection
Positioning
Combination
General
Positioning
Other Accessries
Oxygen Holder-E2208/K0108
Chest Starp-E0960
Cushion Type - ROHO
Joystic Side
Right Side
Left Side
Det./Adj.Arm Type
R-desk & L-Full
R-desk & L-Full
R-desk & L-Full
R&L Full
Color of the PWC
Special Instructions
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ATP Name:
Save Draft
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