Dealer Purchase Order Form

Welcome to Triumph Mobility’s on line ordering for existing dealers. Please complete all form fields. Once the order has been received we will send you an order confirmation for verification before the order ships.

Bill To:
Ship To:
Model Number Description Quantity
Escape Rollator
500-10191 Escape rollator - Charcoal - Super low (19" Seat height)
500-10211 Escape rollator - Charcoal - Low (21" Seat height)
500-10241 Escape rollator - Charcoal - Standard (24" Seat height)
500-10195 Escape rollator - Red - Super low (19" Seat height)
500-10215 Escape rollator - Red - Low (21" Seat height)
500-10245 Escape rollator - Red - Standard (24" Seat height)
500-4000 Slow down brake (set) - Escape Rollator
500-4100 Cane holder - Escape Rollator
500-4200 Cup Holder - Escape Rollator
500-4300 Tray - Escape Rollator
500-4400 Escape Accessories Pack (cane holder, cup holder, & tray)
Rollz Motion
2010RM0010 Rollz Motion2 Pebble White Complete - REGULAR
2010RM0011 Rollz Motion2 Island Blue Complete - REGULAR
2010RM0012 Rollz Motion2 Black Complete - REGULAR
2010RM0013 Rollz Motion2 Dark Purple Complete - REGULAR
2011RM0011 Rollz Motion2 Island Blue Complete - SMALL
2011RM0012 Rollz Motion2 Matt Black Complete - SMALL
1020RM0002 Rollz Motion Cup Holder
1020RM0003 Rollz Motion Cane Holder
1020RM0004 Rollz Motion Premium Shopping Bag
1020RM0010 Travel Cover
1020RM0012 Back Support
2030RM0049 Rollz Motion 3 in 1 Cane, Chair Pack & Bag Holder