JOBST Custom TM Seamed

Transcription

1 SN medical Inc. JOST Custom TM Seamed CUSTOM-MDE VSCULR GRMENTS ORDER FORM DTE: ORIGINL ORDER REORDER HOT-LINE: YES GENDER: MLE FEMLE 3 SEVERITY MILD MODERTE 5 SEVERE DIGNOSIS: Edema Lymphedema Orthostatic Hypotension Thrombotic Syndrome Sclerotherapy/ Vein Ligation Other: List Please Check ppropriate ox(es) PRESCRIED PRESSURE: Venous Ulcer Varicose Veins Venous Insuffi ciency rterial Insuffi ciency* *Physician must indicate compression level on line below or system automatically assigns 25 mmhg: mmhg SN medical File Number PTIENT NME or ID# Date of irth Last Name First Month Year ddress Phone # ( ) Optional PRESCRIER Phone # ddress Specialty DELER / CLINIC / HOSPITL Phone # ( ) cct. # Order confi rmation: Fax No. or address Measured y: Fitter # Prepaid Invoice SHIP TO cct. # ddress ttention ILL TO cct. # ddress Same as 9 ttention P.O. No. VIS MC MEX Expiration Date uth.# Card Number Card Name Federal Law (US) restricts the device to the sale by or on the order of a physician R7-1 - Please enter comments on page 6

2 CUSTOM SEMED RM PTIENT S NME or ID # (if Faxing Order) 12 LTERL (radial) (outside) SPECT (standard) MEDIL (ulnar) (inside) SPECT POSTERIOR (back of hand) NTERIOR (palm of hand) / OPTIONS CT. QTY. QTY. PRICE NO. LEFT RIGHT ECH Detachable Gauntlet (metacarpals to wrist) Half Sleeve (wrist to elbow) Half Sleeve & Gauntlet (metacarpals to elbow) rm Sleeve (wrist to axilla) rm Sleeve and Shoulder Flap rm Sleeve & Gauntlet (metacarpals to axilla) rm Sleeve, Gauntlet and Shoulder Flap OPTIONS Zippers (see box 14) Lining Inside Elbow Lining Full Elbow djustable Shoulder Flap (see box 15) Contracture Seam " Silicone and " Silicone and Standard length zipper is full length. If shorter zipper is desired, please indicate length from wrist LEFT SHOULDER FLP RIGHT ZIPPER OPTIONS LOCTION LENGTH MRK ( ) IN INCHES LEFT RIGHT LEFT RIGHT 16 THUM CIRCUMFERENCE LEFT RIGHT 13 RM CIRCUMFERENCES LEFT TPE# RIGHT / /2 WRIST / / /2 ELOW / / / /2 Length diagonally from top of shoulder to waist or below breast. Give circumference for adjustable fl ap at waist or below breast. 1 1 / R7-2 - Please enter comments on page 6

3 CUSTOM SEMED HND PTIENT S NME or ID # (if Faxing Order) 17 / OPTIONS CT. QTY. QTY. PRICE NO. LEFT RIGHT ECH Glove to Wrist Glove to Elbow Interdigital Web Spacer (to be worn over glove) Mitten OPTIONS Zipper (see box 19) Slant Inserts Pocket for Padding Reinforced Palm or Dorsum Should be taken from outline drawings unless fi ngers are contracted. 18 LENGTHS (HND OUTLINE REQUIRED) For Open Tip, give fi nished length desired Little fi nger to web between little fi nger and ring fi nger 12 Ring fi nger to web between ring and middle fi ngers 13 Middle fi nger to web between middle and index fi ngers 14 Index fi nger and web between middle and index fi ngers 15 Thumb to thumb web 16 Wrist to web between little and ring fi ngers 17 Wrist to web between middle and ring fi ngers 18 Wrist to web between index and middle fi ngers 19 Wrist to thumb web 20 LEFT* RIGHT* 20 Little fi nger DIP 1 Little fi nger PIP 2 Ring fi nger DIP 3 Ring fi nger PIP 4 Middle fi nger DIP 5 Middle fi nger PIP 6 Index fi nger DIP 7 Index fi nger PIP 8 CIRCUMFERENCES LEFT* RIGHT* 19 ZIPPER LOCTION (mark ) LEFT RIGHT Thumb 9 Palm 10 Dorsal (posterior) Ulnar (little fi nger) (standard) Palmar (anterior) Wrist 11 1 /2'' beyond Wrist 3'' beyond Wrist R7-3 - Please enter comments on page 6

4 CUSTOM SEMED TORSO / HED C TORSO / ODY MESUREMENTS CIRCUM HEIGHT PTIENT S NME or ID # (if Faxing Order) 21 CT. PRICE QTY. NO. ECH Sleeveless Vest 1, 10-14, Vest - 1 Long Sleeve 1, 10-14, 17 +arm(s) and 1 Short Sleeve Vest - 2 Short Sleeves 1, 10-14, 17 +arm(s) Vest - 2 Long Sleeves 1, 10-14, 17 +arm(s) Sleeveless ody rief 1, 5, 7, ody rief with Sleeves 1, 5, 7, arm(s) Sleeveless ody Suit 1, 5, 7, leg(s) ody Suit with Sleeves 1, 5, 7, arm(s) & leg(s) Velcro Tabs " Silicone Elastic (eaded Dot Silicone band) " Silicone Elastic (eaded Dot Silicone band) If arm or leg measurements are required go to arm or lower extremity section(s). Desired Top of Support Waist Midpoint etween 1 & 5 Largest Part of uttocks Proximal Thigh Left (at fold of buttocks) ( ) If Yes TORSO / ODY DESIGN CHOICES Front Front ack ack Open Meshed Self V Closure Closure Closure Closure xilla xilla xilla Scoop Neck Zipper Velcro Zipper Velcro LT RT LT RT LT RT Turtleneck Neck Proximal Thigh Right (at fold of buttocks) 9 8 Left Shoulder 10 Right Shoulder 11 Neck Shoulder Width Shoulder to Waist Shoulder to Largest Part of uttocks Shoulder to Fold of uttocks Chest DDITIONL MESUREMENTS FOR R CUPS Shoulder to Just Under reast Circumference Just Under reast Circumference Over Nipple Line * VEST ELOW WIST Shoulder to End of Support Circumference at End of Support C HED MESUREMENTS Width of Eyes Length of Ear Width of Mouth Chin to Eyes Chin to Mouth Circ. above Eyebrow round Head at Chin ngle Circ. of Neck Throat to Sternal Notch Nose Covering cross Tip Nose Covering Length R7-4 - Please enter comments on page / OPTIONS CT. PRICE QTY. NO. ECH Face Mask Open Face Mask Chin Strap Modifi ed Chin Strap (extends behind ear) OPTIONS Nose Covering Lip Covering

5 26 LEG CIRCUMFERENCES LEG CIRCUMFERENCES CUSTOM SEMED LOWER EXTREMITIES LEFT TPE# RIGHT -7 1 / / /2 HEEL /2 +3 Pleat at end of foot only (2 max.) PTIENT S NME or ID # (if Faxing Order) 27 / OPTIONS / COLORS CT. QTY. QTY. QTY. PRICE NO. LEFT RIGHT OTHER ECH nklet Knee Length Thigh Length Waist Height: See ox #22 for ody Measurements Waist Height / Two Legs / Closed Pubis Waist Height / Two Legs / Open Pubis Waist Height / One Leg / Open Pubis Maternity, month of Pregnancy Waist Height / One Leg Panty, Open Pubis Waist Height / One Leg Panty, Closed Pubis Chap Style / One Leg Chap Style / Two Legs INDICTE THE FULL LEG +4 1 / /2 Colors / / / / / / / / /2 +36 Pleat at top only (1 max.) Options Reinforced Heel Full nkle Lining (including heel) Reinforced Knee Lining behind knee Self-material Enclosed Toe (see box 28) Soft Enclosed Toe Zippers (see box 29) Zipper Pull (Plastic) Reduced Panel bdominal Panel ttached Suspenders (under age 6, no charge) Reinforced Inner Thigh & Perineum Oversize Charge (50 to 59 7 / 8 ) Oversize Charge (60 to 69 7 / 8 ) Oversize Charge (70 or greater) " Silicone and " Silicone and " Velcro Tabs (Waist height only) Contracture Seam 28 FOOT MESUREMENTS TOTL LENGTH * Foot length required LEFT RIGHT 29 LTERL (outside) SPECT (standard) MEDIL (inside) SPECT IN ODY ONLY (waist height only) ZIPPER OPTIONS LOCTION LENGTH MRK ( ) IN INCHES LEFT RIGHT LEFT RIGHT R7-5 - Please enter comments on page 6

6 FX YOUR ORDER FORM U.S ORDER SUMMRY SUTOTL $. dd Hot-Line Service Fee - 30% of Subtotal is pplicable. POSTGE & HNDLING SERVICE FEE. $15 OPTIONL OVERNIGHT SHIPPING. INTERNTIONL SHIPPING COST. (TXLE) SUTOTL. DD PPLICLE SLES TX. DDITIONL TX (if any).. Hot-Line PHONE ORDER SERVICE TO OTIN RUSH DELIVERY. SN medical offers a special, high priority phone order service. fter your toll-free phone call, the order will be completed within three work days and rushed to you via FedEx 2nd Day ir or Special Delivery.* Prices of supports so ordered will be increased by 30% to compensate for special handling. This service fee will be withdrawn, automatically, for any order not post-marked within three work days of order date. (Service fee withdrawal does not apply if complete and accurate ordering information is not received with the Hot-Line order.) fter entering all necessary information on this form, call toll-free vailable in U.S.. only. *NEXT DY SHIPPING OPTION (in the U.S..) dd $15.00 to Hot-Line or regular service to select OVERNIGHT SHIPPING. (In areas where available. Weekdays only) Tape Fee - $25.00 TOTL $. Please enclose remittance or P.O., payable in U.S. funds or their equivalent. Sorry, NO C.O.D. s COMMENTS COMMENTS #1 physician recommended SN medical Inc Carnegie lvd. Charlotte, NC Tel. (+1) Fax (+1) To order toll-free: SN medical (+1) ; JOST (+1) Comfort, Health and Style! R SN medical Inc. REV 05/11-6 -