SN medical Inc. JOST Custom TM Seamed CUSTOM-MDE VSCULR GRMENTS ORDER FORM 1 2 4 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 6 7 8 9 10 11 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 E-Mail 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. 52032 R7-1 - Please enter comments on page 6
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 100505 Detachable Gauntlet (metacarpals to wrist) 100515 Half Sleeve (wrist to elbow) 100516 Half Sleeve & Gauntlet (metacarpals to elbow) 100501 rm Sleeve (wrist to axilla) 100503 rm Sleeve and Shoulder Flap 100502 rm Sleeve & Gauntlet (metacarpals to axilla) 100504 rm Sleeve, Gauntlet and Shoulder Flap OPTIONS 101164 Zippers (see box 14) 101167 Lining Inside Elbow 101168 Lining Full Elbow 101172 djustable Shoulder Flap (see box 15) 100176 Contracture Seam 101118 1" Silicone and 100160 2" Silicone and Standard length zipper is full length. If shorter zipper is desired, please indicate length from wrist. 14 15 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 -6-4 1 /2-3 -1 1 /2 WRIST 0 +1 1 /2 +3 +4 1 /2 +6 +7 1 /2 ELOW 9 +10 1 /2 +12 +13 1 /2 +15 +16 1 /2 +18 +19 1 /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 /2 0 3 52032 R7-2 - Please enter comments on page 6
CUSTOM SEMED HND PTIENT S NME or ID # (if Faxing Order) 17 / OPTIONS CT. QTY. QTY. PRICE NO. LEFT RIGHT ECH 100535 Glove to Wrist 100534 Glove to Elbow 100536 Interdigital Web Spacer (to be worn over glove) 100537 Mitten OPTIONS 101164 Zipper (see box 19) 101169 Slant Inserts 100027 Pocket for Padding 100021 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 52032 R7-3 - Please enter comments on page 6
CUSTOM SEMED TORSO / HED 13 22 12 11 10 17 17 C 16 15 14 1 1 9 7 3 5 7 9 8 6 4 2 TORSO / ODY MESUREMENTS CIRCUM HEIGHT PTIENT S NME or ID # (if Faxing Order) 21 CT. PRICE QTY. NO. ECH 100525 Sleeveless Vest 1, 10-14, 17 100524 Vest - 1 Long Sleeve 1, 10-14, 17 +arm(s) and 1 Short Sleeve 100526 Vest - 2 Short Sleeves 1, 10-14, 17 +arm(s) 100527 Vest - 2 Long Sleeves 1, 10-14, 17 +arm(s) 100530 Sleeveless ody rief 1, 5, 7, 9-17 100531 ody rief with Sleeves 1, 5, 7, 9-17 + arm(s) 100558 Sleeveless ody Suit 1, 5, 7, 9-17 + leg(s) 100560 ody Suit with Sleeves 1, 5, 7, 9-17 + arm(s) & leg(s) 101163 Velcro Tabs 101118 1" Silicone Elastic (eaded Dot Silicone band) 100160 2" 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) 1 2 3 4 5 6 7 8 23 ( ) 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 12 17 C 13 14 15 16 24 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 52032 R7-4 - Please enter comments on page 6 1 2 3 4 5 6 7 8 9 25 / OPTIONS CT. PRICE QTY. NO. ECH 100540 Face Mask 101158 Open Face Mask 100550 Chin Strap 100549 Modifi ed Chin Strap (extends behind ear) OPTIONS 101165 Nose Covering 101166 Lip Covering
26 LEG CIRCUMFERENCES LEG CIRCUMFERENCES CUSTOM SEMED LOWER EXTREMITIES LEFT TPE# RIGHT -7 1 /2-6 -4 1 /2-3 -1 1 /2 HEEL 0 +1 1 /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 100105 nklet 100101 Knee Length 100201 Thigh Length Waist Height: See ox #22 for ody Measurements 101101 Waist Height / Two Legs / Closed Pubis 101102 Waist Height / Two Legs / Open Pubis 101103 Waist Height / One Leg / Open Pubis 101104 Maternity, month of Pregnancy 101112 Waist Height / One Leg Panty, Open Pubis 101113 Waist Height / One Leg Panty, Closed Pubis 100035 Chap Style / One Leg 100036 Chap Style / Two Legs INDICTE THE FULL LEG +4 1 /2 +6 +7 1 /2 Colors +9 +10 1 /2 +12 +13 1 /2 +15 +16 1 /2 +18 +19 1 /2 +21 +22 1 /2 +24 +25 1 /2 +27 +28 1 /2 +30 +31 1 /2 +33 +34 1 /2 +36 Pleat at top only (1 max.) Options 101187 Reinforced Heel 101188 Full nkle Lining (including heel) 101186 Reinforced Knee 100040 Lining behind knee 101159 Self-material Enclosed Toe (see box 28) 101160 Soft Enclosed Toe 101164 Zippers (see box 29) 101108 Zipper Pull (Plastic) 101161 Reduced Panel bdominal Panel 101162 ttached Suspenders (under age 6, no charge) 101185 Reinforced Inner Thigh & Perineum 101177 Oversize Charge (50 to 59 7 / 8 ) 100031 Oversize Charge (60 to 69 7 / 8 ) 100042 Oversize Charge (70 or greater) 101118 1" Silicone and 100160 2" Silicone and 101163 1" Velcro Tabs (Waist height only) 100176 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 52032 R7-5 - Please enter comments on page 6
FX YOUR ORDER FORM U.S.. 1-800-835-4325 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 1-800-537-1063. 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. 5825 Carnegie lvd. Charlotte, NC 28209-4633 Tel. (+1) 704 554 9933 Fax (+1) 800 835 4325 www.jobst.com To order toll-free: SN medical (+1) 800 552 1157; JOST (+1) 800 537 1063 Comfort, Health and Style! 52032 R7 2011 SN medical Inc. REV 05/11-6 -