Jobst Custom TM Seamed

Transcription

1 SN-JOST Jobst Custom TM Seamed CUSTOM-MDE VSCULR GRMENTS ORDER FORM GENDER: DTE: ORIGINL ORDER REORDER HOT-LINE: YES MLE FEMLE DIGNOSIS: Edema Lymphedema Orthostatic Hypotension Thrombotic Syndrome Sclerotherapy/ Vein Ligation Please Check ppropriate ox(es) Venous Ulcer Varicose Veins Venous Insufficiency rterial Insufficiency* *Physician must indicate compression level on line below or system automatically assigns 25 mmhg: mmhg SN-JOST File Number PTIENT NME or ID# Date of irth Last Name First 3 SEVERITY MILD MODERTE SEVERE PRESCRIED PRESSURE: ddress Phone # ( ) PRESCRIER Phone # ddress Specialty DELER / CLINIC / HOSPITL Phone # ( ) cct. # Order confirmation: Fax No. or address Measured y: Fitter # Prepaid Invoice Optional ILL TO cct. # ddress Same as 9 ttention P.O. No. CHECK VIS Card Number 5 Month Year SHIP TO cct. # ddress ttention MSTERCRD MEX Expiration Date uth.# Federal Law (US) restricts the device to the sale by or on the order of a physician R3-1 - Please enter comments on page 6

2 CUSTOM SEMED - RM PTIENT'S NME or ID # (if Faxing Order) 12 CT. QTY. QTY. PRICE NO. ECH Detachable Gauntlet (metacarpals to wrist) Forearm Sleeve (wrist to elbow) Forearm 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) Silicone and / OPTIONS 13 PLETS RM CIRCUMFERENCES TPE# PLETS / / / /2 +6 Standard length zipper is full length. If shorter zipper is desired, please indicate length from wrist. 14 LTERL (radial) (outside) SPECT MEDIL (ulnar) (inside) SPECT POSTERIOR (back of hand) NTERIOR (palm of hand) (standard) ZIPPER OPTIONS LOCTION LENGTH MRK ( ) IN INCHES +7 1 /2 ELOW / / /2 15 SHOULDER FLP 16 THUM CIRCUMFERENCE /2 Length diagonally from top of shoulder to waist or below breast. Give circumference for adjustable flap at waist or below breast R3-2 - 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. ECH Glove to Wrist Glove to Elbow Interdigital Web Spacer (to be worn over glove) Mitten OPTIONS Zipper (see box 19) Slant Inserts Should be taken from outline drawings unless fingers are contracted. 18 LENGTHS (hand outline required) For Open Tip, give finished length desired Little finger to web between little finger and ring finger 12 Ring finger to web between ring and middle fingers 13 Middle finger to web between middle and index fingers 14 Index finger and web between middle and index fingers 15 Thumb to thumb web 16 Wrist to web between little and ring fingers 17 Wrist to web between middle and ring fingers 18 Wrist to web between index and middle fingers 19 Wrist to thumb web 20 * * 20 Little finger DIP 1 Little finger PIP 2 Ring finger DIP 3 Ring finger PIP 4 Middle finger DIP 5 Middle finger PIP 6 Index finger DIP 7 Index finger PIP 8 CIRCUMFERENCES * * 19 ZIPPER LOCTION (mark ) Thumb 9 Palm 10 Dorsal (posterior) Ulnar (little finger) (standard) Palmar (anterior) Wrist /2" beyond Wrist 3" beyond Wrist R3-3 - Please enter comments on page 6

4 CUSTOM SEMED - TORSO / HED C Desired Top of Support Waist Midpoint etween 1 & 5 Largest Part of uttocks Proximal Thigh Left (at fold of buttocks) Proximal Thigh Right (at fold of buttocks) Left Shoulder Right Shoulder 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 TORSO / ODY MESUREMENTS C CIRCUM PTIENT'S NME or ID # (if Faxing Order) HEIGHT 21 ( ) If Yes CT. NO Sleeveless Vest 1, 10-14, Vest - 2 Long Sleeves 1, 10-14, (1 with Gauntlet) 17 + arm(s) + hand Vest - Long Sleeve and 1, 10-14, Gauntlet / Short Sleeves 17 + arm(s) + hand 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) Vest - 2 Long Sleeves 1, 10-14, with Gauntlets 17 +arm(s) + hand(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 23 Front Front ack ack Open Meshed Self Standard Closure Closure Closure Closure xilla xilla xilla xilla T-neck Zipper Velcro Zipper Velcro LT RT LT RT LT RT LT RT 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 PRICE ECH R3-4 - Please enter comments on page 6 QTY. If arm or leg measurements are required go to arm or lower extremity section(s). 24 HED MESUREMENTS TORSO / ODY DESIGN CHOICES CT. NO. / OPTIONS Face Mask Open Face Mask Chin Strap Modified Chin Strap (extends behind ear) Chin Extension Collar OPTIONS Nose Covering Lip Covering QTY. Scoop Neck PRICE ECH

5 CUSTOM SEMED - LOWER EXTREMITIES 26 LEG CIRCUMFERENCES LEG CIRCUMFERENCES PLETS TPE# -7 1 / / /2 HEEL /2 +3 PLETS 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. OTHER ECH nklet Knee Length Thigh Length Waist High: Check ox # 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 +36 Pleat at top only (1 max.) 28 FOOT MESUREMENTS Colors lack 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) 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 Contracture Seam Velcro Tabs Silicone Elastic LENGTH LTERL (outside) SPECT (standard) MEDIL (inside) SPECT IN ODY ONLY (begins at top) ZIPPER OPTIONS LOCTION LENGTH MRK ( ) IN INCHES R3-5 - Please enter comments on page 6 29

6 FX YOUR ORDER FORM rightlife Direct: ORDER SUMMRY SUTOTL $. dd Hot-Line Service Fee - 30% of Subtotal is pplicable. POSTGE & HNDLING SERVICE FEE. $10 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-JOST 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 UPS 2nd Day ir or Special Delivery.* Prices of supports so ordered will be increased by 30 percent 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 withdrawl 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 $10.00 to Hot-Line or regular service to select OVERNIGHT SHIPPING. (In areas where available. Weekdays only) TOTL $. Please enclose remittance or P.O., payable in U.S. funds or their equivalent. Sorry, NO C.O.D.'s JOST Custom Seamless Soft Prescription Order Form (52457) and JOST Custom Seamless Soft Order Form (52456) are also available. COMMENTS COMMENTS SN-JOST, Inc Carnegie lvd., Charlotte, NC PO ox , Charlotte, NC U.S.. To order toll free Tel. Fax for international use: R3 = registered trademark SN-JOST, Inc. Printed in U.S. Rev. 2/03