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Go-Go Elite Traveller® - 3 and 4 Wheel Scooter Quick Ship Order Form

Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: prideorders@pridemobility.com

Account Number: ___________ Date: ________________

Provider Name: __________________________________

Contact: ________________________________________

Phone: ___________________ Fax: _________________

Email: __________________________________________

PO Number: _____________________________________

Marked for: _____________________________________

Ship to Address: _________________________________

City: _____________________ State: ______ Zip: ______

ACCESSORIESOptional.

Micro, Black, Weather Cover .............................................$114Part: ACCCOVR1020

Rear View Mirror .................................................................. $25Part: ACC134496

Cup Holder ............................................................................ $20Part: ACCASMB2288

50" Lap Belt ................................................................ StandardPart: ACCBELT1000

Safety Flag ............................................................................ $38Part: ACCASMB2079

Saddle Bag (12.5" x 9.875") ................................................ $35Part: DWR1020D010

Under Seat Storage ............................................................. $80Part: ACC160129

MODELREQUIRED. 300 lb. weight capacity. More details and specifications at found at pridemobility.com/scooters.

Go-Go Elite Traveller, 3-Wheel ...................................... $1,499Part: SC40E. HCPCS: K0800 - Group 1/Standard

Go-Go Elite Traveller, 4-Wheel ..................................... $1,599Part: SC44E. HCPCS: K0800 - Group 1/Standard

Includes standard options:• Red, Blue shroud panels• 2-Amp off-board charger• Front Basket• Flat-free tires• Foldable, Molded plastic seat (17"W x 17"D)• Removable Footboard Basket (4-wheel Models Only)

BATTERY BOX SELECTIONREQUIRED.

12Ah Battery Box ....................................................... StandardIncludes two 12Ah BatteriesPart: BATASMB1028

18Ah Battery Box ...............................................................$150Includes two 18Ah BatteriesPart: BATASMB1029

This form is interactive when viewed in Adobe Acrobat Reader and may not function correctly if opened with applications other than Acrobat. HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for determining the appropriate billing codes when submitting for insurance reimbursement. Payer coding, coverage, and bundling guidelines may apply. All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete scooter. Please contact technical service for accurate parts ordering.

Thank you for choosing Pride Mobility Products!

INTRODUCTION

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Account Number: ___________ Date: ________________ Marked for: _____________________________________

COMMENTS

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Air Force Patch ............................... $20Part: ACC140240

Army Patch ..................................... $20Part: ACC140241

Coast Guard Patch ........................ $20Part: ACC140239

Marines Patch ................................. $20Part: ACC140243

Navy Patch ...................................... $20Part: ACC140244

Purple Heart Patch ........................ $20Part: ACC140238

BRANCH PATCHESOptional.

Air Force Patch ............................... $20Part: ACC140240

Army Patch ..................................... $20Part: ACC140241

Coast Guard Patch ........................ $20Part: ACC140239

Marines Patch ................................. $20Part: ACC140243

Navy Patch ...................................... $20Part: ACC140244

Purple Heart Patch ........................ $20Part: ACC140238

CANE/CRUTCH HOLDEROptional. Only one cane/crutch holder can be used at a time.

Wishbone Crutch Holder .................................................... $98Part: FRMASMB2358

Forearm Crutch Holder ....................................................... $98Part: ACCASMB1019

Single Rear Mount, 3" ..........................................................$70Part: ACCINDV1058

Double Rear Mount, 3" .........................................................$70Part: ACCINDV1019

Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: prideorders@pridemobility.com

Mobility Made Easy. Pride offers a variety of lifts to transport your mobility product with ease. To find a compatible lift for your vehicle and mobility product, use our new Lift Finder applica-tion at pridemobility.com/lift-finder

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Rear Basket (15.25" x 9.75" x 9.5") .................................... $80 Part: ACCBSKT1010

Oxygen Holder ..................................................................... $98Part: ACCASMB1017

Walker Holder ....................................................................... $98Part: ACCASMB1018

ACCESSORIES ContinuedOptional. Only one back mounted accessory can be used at a time. Includes mounting bracket and hardware.

Back Mounted Accessories