Sunrise Medical XT4 Powerchair

Order Form and Technical Specifications

Product Information

The XT4 is a versatile powerchair designed for a variety of users. This document serves as an order form and provides detailed specifications for customization.

Base Price (excluding VAT): €24.000,00

Order Information

Please fill out the following sections for billing and shipping details.

Billing Information (FATTURARE A)

Company Name (Ragione Sociale)
Street (Via)
City (Città)
Province / Postal Code (Provincia / C.A.P.)
Email (e-mail)
Telephone (Telefono)

Shipping Information (SPEDIRE A)

Identical to billing address

Company Name (Ragione Sociale)
Street (Via)
City (Città)
Province / Postal Code (Provincia / C.A.P.)
Email (e-mail)
Telephone (Telefono)

Order Details

Order Information (INFORMAZIONI SULL'ORDINE)

Order Type: Order Quote Built-4-Me®

Order Number (N° Ordine):

Item Number (Art. No.):

Order Date (Data ordine): Day: Month: Year:

User Weight (PESO DELL'UTENTE)

Maximum Load Capacity: 160 kg

User Weight: kg

User Measurements (MISURE DELL'UTENTE)

Please provide the following measurements in mm:

a) Top of head to seat[ ]mm
b) Shoulder to seat[ ]mm
c) Axilla to seat[ ]mm
d) Shoulder width[ ]mm
e) Trunk width[ ]mm
f) Current wheelchair seat width[ ]mm
g) Current wheelchair seat depth[ ]mm
h) Popliteal fossa to floor[ ]mm

A diagram illustrates these measurements.

Technical Data (Dati Tecnici)

FeatureSpecification
Maximum Load Capacity160 kg (with combined elevation and tilt module)
Ground Clearance125 mm
Total Width700 mm
Overall Length1000 mm
Drive WheelsPneumatic off-road wheels, black rims
ElectronicsR-Net
Battery Charger220 V / 12 A
Batteries115 Ah, 58 km range
Motors4-pole 10 km/h (4 x 700 W)
Turning Radius1410 mm

Base and Colors (Base motrice e Colori XT4)

CategoryOption CodeDescriptionStandardPrice (€)
BaseMAG010013XT4STD
XT4 ColorsMAG6094XT4 Midnight Black
MAG6095XT4 Sunset Red
MAG6096XT4 Horizon Blue

Drive Wheels (Ruote Motrici)

Option CodeDescriptionStandardPrice (€)
MAG7050Pneumatic low pressure tiresSTD
MAG7056Pneumatic tires with puncture-resistant insert514.00
MAG7058Neverflat (internal tire treatment to prevent pressure loss from punctures)170.00

Batteries and Charger (Batterie e Caricabatterie)

Option CodeDescriptionStandardPrice (€)
MAG6285115 Ah BatteriesSTD
MAG160106Automatic charger 220V/12ASTD

Seat Electronics Modules (Moduli elettronici della seduta)

Option CodeDescriptionStandardPrice (€)
MAG5127Electronic tilt 0° to 50°
MAG5126Combined electronic lift (300 mm) and tilt 0° to 45°STD1431.00

Seat Height to Floor (Altezza della seduta a terra)

(Does not include cushion height)

Option CodeDescriptionStandardPrice (€)
MAG6552480 mm (max. footrest length 370 mm)STD
MAG6553+25 mm (max. footrest length 400 mm)106.00
MAG6554+50 mm (max. footrest length 430 mm)

Seat Type (Tipologia di seduta)

Option CodeDescriptionStandardPrice (€)
MAGMPSSEATVINYLMPS Seat, Vinyl upholstery (See Section A) (only with MPS backrest)STD
MAGMPSSEATFABRICMPS Seat, Fabric upholstery (See Section A) (only with MPS backrest)
MAGREHABSITRehab Seat, choose JAY cushion type

Section A - MPS Seat Cushion Measurements

Seat Cushion Width (Larghezza del cuscino)

Refer to the illustrative image for MPS seat measurements.

Option CodeWidth
MAGSW405MM405 mm[ ]
MAGSW455MM455 mm[ ]
MAGSW510MM510 mm[ ]
MAGSW560MM560 mm[ ]
MAGSW610MM610 mm[ ]

Cancel Selection

Seat Cushion Depth (Profondità del cuscino)

Note: For seat widths of 405 mm and 430 mm, depths greater than 455 mm are only possible with special production.

Option CodeDepth
MAGSD405MM405 mm[ ]
MAGSD455MM455 mm[ ]
MAGSD510MM510 mm[ ]

Cancel Selection

Section B - Rehab Seat Plate Measurements

Seat Plate Width (Larghezza della piastra della seduta)

(Seat depth minus seat width should not exceed 50 mm)

MAGSW305MM305 mm[ ]MAGSW430MM430 mm[ ]MAGSW560MM560 mm[ ]
MAGSW330MM330 mm[ ]MAGSW455MM455 mm[ ]MAGSW585MM585 mm[ ]
MAGSW355MM355 mm[ ]MAGSW480MM480 mm[ ]MAGSW610MM610 mm[ ]
MAGSW380MM380 mm[ ]MAGSW510MM510 mm[ ]MAGSW535MM535 mm[ ]
MAGSW405MM405 mm[ ]

Cancel Selection

Seat Plate Depth (Profondità della piastra della seduta)

(Seat depth minus seat width should not exceed 50 mm)

MAGSD305MM305 mm[ ]MAGSD430MM430 mm[ ]MAGSD560MM560 mm[ ]
MAGSD330MM330 mm[ ]MAGSD455MM455 mm[ ]MAGSD585MM585 mm[ ]
MAGSD355MM355 mm[ ]MAGSD480MM480 mm[ ]MAGSD610MM610 mm[ ]
MAGSD380MM380 mm[ ]MAGSD510MM510 mm[ ]MAGSD535MM535 mm[ ]
MAGSD405MM405 mm[ ]

Cancel Selection

Section B - Rehab Seat Cushion (Sezione B - Cuscino per seduta Rehab)

Option CodeDescriptionStandardPrice (€)
MAGWOSEATCUSHWithout cushion

Jay Cushion (Cuscino JAY)

Choose Jay Cushion, indicate code (see Jay section on our website).

DescriptionReference
Jay CushionSee Jay Sheet

Backrest Type (Tipologia di schienale)

Option CodeDescriptionStandardPrice (€)
MAGMPSBACKMPS (only with MPS seat)STD
MAGREHABCANESRehab (choose JAY backrest type)509.00
MAGREHABSITRehab flip-back (choose JAY backrest type)

MPS Backrest Upholstery (Rivestimento dell'imbottitura schienale MPS)

Option CodeDescriptionStandardPrice (€)
MAGFABRICBRFabric upholsterySTD
MAGVINYLBRVinyl upholstery

MPS Backrest Pad Measurements (Misure dell'imbottitura schienale MPS)

Backrest Pad Width (Larghezza dell'imbottitura)

(Backrest height minus backrest width should not exceed 50 mm)

Option CodeWidth
MAGBW405MM405 mm[ ]
MAGBW455MM455 mm[ ]
MAGBW510MM510 mm[ ]
MAGBW560MM560 mm[ ]
MAGBW610MM610 mm[ ]

Cancel Selection

Backrest Pad Height (Altezza dell'imbottitura)

(Backrest height minus backrest width should not exceed 50 mm)

Option CodeHeight
MAGBH535MM535 mm[ ]
MAGBH585MM585 mm[ ]

Cancel Selection

Backrest Recline Modules (Moduli reclinazione dello schienale)

MPS Seat Backrest Recline Modules (Moduli reclinazione dello schienale con seduta MPS)

Option CodeDescriptionStandardPrice (€)
MAG3900-S-3901-FManual recline 90° to 170°STD
MAG3904-S-3905-FElectronic recline 90° to 150° (not with MAG3502-KIT)954.00

Rehab Seat and Backrest Recline Modules (Moduli reclinazione dello schienale per la seduta Rehab e schienale Rehab)

Option CodeDescriptionStandardPrice (€)
MAG3924-S-3925-FManual recline 90° to 170°
MAG3928-S-3929-FElectronic recline 90° to 160°1569.00
MAG3932-S-3933-FElectronic recline with compensation 95° to 155° (not with seat widths 305, 330, 355 mm)

Rehab Seat with Flip-Back Backrest Recline Modules (Moduli reclinazione dello schienale per seduta Rehab con schienale abbattibile in avanti)

Option CodeDescriptionStandardPrice (€)
MAG3926-S-3927-FManual recline 90° to 170°954.00
MAG3930-S-3931-FElectronic recline 90° to 160°1569.00
MAG3934-S-3935-FElectronic recline with compensation 95° to 155° (not with seat widths 305, 330, 355 mm)

Rehab Backrest, Jay Type (Schienale Rehab, tipologia di schienale JAY)

Jay Backrest, Jay Type (Schienale Rehab, tipologia di schienale JAY)

DescriptionReference
Jay J3 BackrestChoose Jay backrest, indicate code (see Jay section on our website) (select without backrest upholstery)See Jay Sheet

Push Handles (Maniglie di spinta)

Option CodeDescriptionStandardPrice (€)
MAG0057-PIPush handle for MPS backrest (only with MPS backrest)85.00
MAGPRHAHeight-adjustable push handles for MPS backrest (only with MPS backrest)302.00
MAG0056-WOKOR-2Push handles for MPS backrest69.00
MAG46354636Push handles for Rehab backrest69.00

Backrest Accessories (Accessori dello schienale)

Option CodeDescriptionStandardPrice (€)
MAG5724Backpack hooks, mounted on MPS backrest (pair)32.00
MAG5723Backpack hooks, mounted on Rehab push handle (pair)32.00

Headrest Type (Tipologia di appoggiatesta)

MPS Headrest (Appoggiatesta MPS)

Option CodeDescriptionStandardPrice (€)
MAG2770VIMPS (only with MPS backrest) (upholstery will match the backrest)STD

Whitmyer Headrest (Appoggiatesta Whitmyer)

Choose Whitmyer Headrest (only with Jay backrest) (see Whitmyer section on our website). Indicate padding code: (includes mounting bracket and attachment plate).

DescriptionReference
Whitmyer HeadrestSee Whitmyer Sheet

Armrest Type (Tipologia di braccioli)

Option CodeDescriptionStandardPrice (€)
MAG3572Standard Single Post, removable260.00
MAG3994Standard Single Post, removable with reinforcement (bariatric users)890.00
MAGFLEXIARMFlip-up (flexi)1158.00
MAG6503-6502Flip-up with support stem for seat (flexi)1158.00
MAG3331-6500Flip-up with support stem for seat to lock position (flexi)1158.00
MAG3727-6501Flip-up with support stem for seat and flip-down (flexi) (to allow closer approach to tables)

Armrest Height (Altezza dei braccioli)

Select the desired height in mm:

MAGAH220MM220 mm[ ]MAGAH230MM230 mm[ ]MAGAH240MM240 mm[ ]MAGAH250MM250 mm[ ]MAGAH260MM260 mm[ ]
MAGAH270MM270 mm[ ]MAGAH280MM280 mm[ ]MAGAH290MM290 mm[ ]MAGAH300MM300 mm[ ]MAGAH310MM310 mm[ ]
MAGAH320MM320 mm[ ]MAGAH330MM330 mm[ ]MAGAH340MM340 mm[ ]MAGAH350MM350 mm[ ]MAGAH360MM360 mm[ ]
MAGAH370MM370 mm[ ]MAGAH380MM380 mm[ ]MAGAH390MM390 mm[ ]

Armrest Padding (Imbottiture dei braccioli)

Option CodeDescriptionStandardPrice (€)
MAGAP75-WOKOR-2Comfort, 75 mm lengthSTD
MAG3971-3972MPS, P-shaped padding, 100 mm width
MAG3712MPS, P-shaped padding, flip-up side, 100 mm width378.00
MAGAP50-2Standard, 50 mm width378.00
MAG6711Waterfall - Armrests with lower side protection442.00
MAG3775Gutter - Wrap-around padding442.00
MAG6750Gutter - Wrap-around padding with elbow support472.00
MAG6751Gutter - Wrap-around padding with palm support472.00
MAG6752Gutter - Wrap-around padding with elbow and palm support

Armrest Upholstery Type (Tipologia di rivestimento dei braccioli)

Option CodeDescriptionStandardPrice (€)
MAGAPVINYLVinyl upholsterySTD
MAGAPFABRICFabric upholstery32.00

Armrest Options (Opzioni dei braccioli)

Option CodeDescription
MAGHOOKA2RHBag hooks, fitted to right armrest[ ]
MAGHOOKA2LHBag hooks, fitted to left armrest[ ]

Footplate Height (Altezza del piatto pedana)

Select the desired height in mm:

MAGLL300MM300 mm[ ]MAGLL330MM330 mm[ ]MAGLL360MM360 mm[ ]MAGLL390MM390 mm[ ]MAGLL420MM420 mm[ ]
MAGLL310MM310 mm[ ]MAGLL340MM340 mm[ ]MAGLL370MM370 mm[ ]MAGLL400MM400 mm[ ]MAGLL430MM430 mm[ ]
MAGLL320MM320 mm[ ]MAGLL350MM350 mm[ ]MAGLL380MM380 mm[ ]MAGLL410MM410 mm[ ]

Note: MAGLL380MM, MAGLL390MM, MAGLL400MM, MAGLL410MM are not compatible with MAG6552 standard seat height.

Footplate Type (Tipologia di pedana)

Option CodeDescriptionStandardPrice (€)
MAGCPLEGRESTCentral footplate (calf supports not included)STD1841.00
MAGCPOWERCentral elevating footplate (calf supports included)516.00
MAG3528Swing away 70° footplates964.00
MAG3527-MEManually elevating swing away footplates (calf supports not included)1984.00
MAG3526-MEElectronically elevating swing away footplates (calf supports not included)

Footplate Pad (Piatto pedana)

Option CodeDescriptionStandardPrice (€)
MAG4055Single flip-up footplate pad, 260 mm width (central footplate only)STD
MAG4055-2Split flip-up footplate pads, 260 mm width (central footplate only)219.00
MAG4755Single flip-up footplate pad (central elevating electronic footplate only)
MAG4755-2Split flip-up footplate pads (central elevating electronic footplate only)
MAGFLIPUPSplit flip-up footplate pads (swing away footplates only)

Footplate Accessories (Accessori delle pedane)

Option CodeDescriptionPrice (€)
MAG4312Lock for split footplate pads (swing away footplates only)80.00

Calf Supports (Supporti per i polpacci)

Option CodeDescription
MAGCALFSUPPORTCalf supports (not required with the central electronic elevating footplate)[ ]

Knee Padding (Imbottiture per le ginocchia)

Option CodeDescriptionStandardPrice (€)
MAG4247Knee padding504.00
MAGKPCMPEKnee padding for central electronic elevating footplate251.00
MAG4660Knee padding for 70° swing away footplates504.00
MAG4104Knee padding for swing away elevating footplates251.00

Seatbelts (Cinture)

Option CodeDescriptionStandard
MAG4730Wrap-around seatbelt with auto-type buckle for Rehab seatSTD
MAGLBLHLeft attachment[ ]
MAGLBRHRight attachment[ ]
MAG4731Wrap-around seatbelt with auto-type buckle for MPS seatSTD
MAGLBLHLeft attachment[ ]
MAGLBRHRight attachment[ ]

Joystick R-Net

Option CodeDescriptionStandardPrice (€)
MAGPG-JSMLEDLJoystick R-Net with LED
MAGPG-JSM-PIJoystick R-Net with color LCDSTD1187.00
MAGPG-JSMIRBTJoystick R-Net LCD ADVANCE with Bluetooth and IR (Android, Windows, iOS)

R-Net Display Language (Lingua del display R-Net)

Option CodeLanguageStandard
MAG119005ItalianSTD

Control+5 Module

Option CodeDescriptionStandardPrice (€)
MAG158709Switch Box CTRL5 with push buttons724.00
MAG158708Switch Box CTRL5 with levers724.00

Switch Box CTRL5 Mounting Position (Posizione di montaggio Switch Box CTRL5)

Option CodeDescription
MAG5430Mounting on armrest, same side as Joystick[ ]
MAG5431Mounting on armrest, opposite side of Joystick[ ]
MAG5432Mounting for attendant (mounted on the rear of the push handle)[ ]

Joystick Grips (Impugnature del joystick)

Option CodeDescriptionPrice (€)
MAGKNOBSTDStandard Grip34.00
MAGPG-KS80Long lever grip, 80 mm34.00
MAGPG-KCHINChin grip, 38 mm diameter34.00
MAGPG-KB32Ball grip, 32 mm diameter34.00
MAGPG-KB38Ball grip, 38 mm diameter34.00
MAGPG-KM48Mushroom grip, 48 mm diameter34.00
MAGPG-KTBART-Bar grip, 80 mm width34.00
MAGPG-KSB70Soft ball grip, 70 mm diameter34.00

Joystick Positioning (Posizionamento del joystick)

Option CodePositionStandardPrice (€)
MAGJSRIGHTRightSTD
MAGJSLEFTLeft
MAGPGCYPGC2.03725Interchangeable right/left420.00
MAG3330JSM-RHAttaches as attendant control on the right, for MPS backrest371.00
MAG3330JSM-LHAttaches as attendant control on the left, for MPS backrest371.00
MAG3329JSM-RHAttaches as attendant control on the right, for Rehab backrest371.00
MAG3329JSM-LHAttaches as attendant control on the left, for Rehab backrest371.00

Joystick Mounting Bracket (Braccetto di montaggio del joystick)

Option CodeDescriptionStandardPrice (€)
MAG110050FixedSTD
MAG3083-KIT-OSSwing away outwards (with magnet)371.00
MAG3083-KIT-ISSwing away inwards (with magnet)371.00
MAG3082-KIT-OSSwing away outwards with latch371.00
MAG3082-KIT-ISSwing away inwards with latch371.00

Joystick Anchor Support (Supporto di ancoraggio per il joystick)

Option CodeDescriptionStandardPrice (€)
MAG4980Height adjustable for fixed joystick mounting bracketSTD
MAG3713Height adjustable for swing away joystick mounting bracket106.00
MAG3729STDRemovable for fixed joystick mounting bracket53.00
MAG3729SBRemovable for swing away joystick mounting bracket53.00

Alternative Controls (Controlli alternativi)

Option CodeDescriptionStandardPrice (€)
MAG5436R-Net OMNI2 Module with Bluetooth and IR (includes interface for special controls)1000.00

OMNI2 Mounting Position (Posizione di montaggio OMNI2)

Left: MAGOMNILH, Right: MAGOMNIRH

Attendant Control (Comando per accompagnatore)

Option CodeDescriptionStandardPrice (€)
MAG3330AM-KITStandard attendant control, for MPS backrest1073.00
MAG3329AM-KITStandard attendant control, for Rehab backrest1073.00

Mounting Position (Posizione di montaggio)

Left: MAGACLH, Right: MAGACRH

Accessories (Accessori)

Option CodeDescriptionPrice (€)
MAG4471Cup holder RAM®206.00
MAG4627Magic Mobility stainless steel cup holder231.00
MAG4478Combined Magic Mobility cup holder and phone holder284.00
MAG4705USB charging ports (2xUSB and 1x12V) - fitted to seat side rail, same side as joystick271.00
MAG6629USB charging ports (2xUSB) - fitted to seat side rail, opposite side of joystick251.00
MAG4801USB charging ports (2xUSB) - fitted to seat side rail, same side as joystick251.00
MAG6594USB charging ports (2xUSB) - fitted to armrest, opposite side of joystick251.00
MAG5360Upgraded horn167.00
MAG4834Storage bag (fitted to backrest)148.00
MAG4834RHStorage bag (fitted to right armrest)148.00
MAG4834LHStorage bag (fitted to left armrest)148.00
MAG4834-2Storage bags (fitted to both armrests)148.00
MAGCOVERWheelchair cover235.00

Tables (Tavolini)

Table Options

Clear polycarbonate table shown below. Black HD plastic is also available (typically without folded edges).

Unless a drawing has been supplied with specifications for cut out sizes for stomach and joystick, the slide-in and swing-over tables will be provided as a kit.

Table TypeDescriptionPrice (€)
SLIDE IN LARGE TABLETable rests on armpad opposite to stem588.00
DOUBLE STEM LARGE TABLEFor chairs with attendant control ONLY (no joystick)588.00
SWINGAWAY SMALL TABLEWidth 320 x Depth 240
SWINGOVER LARGE TABLETable rests on both armpads

Final Price Calculation

Extreme XT4

Base Price (IVA 4% esclusa)€24.000,00
Options (IVA 4% esclusa)
Total Price (IVA 4% esclusa)

Order Confirmation

Date: Day: Month: Year:

Signature:

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