SN-JOST Jobst Custom TM Seamed CUSTOM-MDE VSCULR GRMENTS ORDER FORM 1 2 4 GENDER: DTE: ORIGINL ORDER REORDER HOT-LINE: 6 7 8 9 10 11 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 E-Mail 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. 52032 R3-1 - Please enter comments on page 6
CUSTOM SEMED - RM PTIENT'S NME or ID # (if Faxing Order) 12 CT. QTY. QTY. PRICE NO. ECH 100505 Detachable Gauntlet (metacarpals to wrist) 100515 Forearm Sleeve (wrist to elbow) 100516 Forearm 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) 101118 Silicone and / OPTIONS 13 PLETS RM CIRCUMFERENCES TPE# PLETS -6-4 1 /2-3 -1 1 /2 0 +1 1 /2 +3 +4 1 /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 9 +10 1 /2 +12 +13 1 /2 +15 +16 1 /2 15 SHOULDER FLP 16 THUM CIRCUMFERENCE +18 +19 1 /2 Length diagonally from top of shoulder to waist or below breast. Give circumference for adjustable flap at waist or below breast. 52032 R3-2 - Please enter comments on page 6
CUSTOM SEMED - HND PTIENT'S NME or ID # (if Faxing Order) 17 / OPTIONS CT. QTY. QTY. PRICE NO. 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 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 11 1 1/2" beyond Wrist 3" beyond Wrist 52032 R3-3 - Please enter comments on page 6
CUSTOM SEMED - TORSO / HED 22 13 12 11 10 17 17 C 16 15 14 1 1 9 7 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 3 5 7 9 8 6 4 2 TORSO / ODY MESUREMENTS 1 2 3 4 5 6 7 8 9 8 10 11 12 17 C CIRCUM 13 14 15 16 PTIENT'S NME or ID # (if Faxing Order) HEIGHT 21 ( ) If Yes CT. NO. 100525 Sleeveless Vest 1, 10-14, 17 100522 Vest - 2 Long Sleeves 1, 10-14, (1 with Gauntlet) 17 + arm(s) + hand 100523 Vest - Long Sleeve and 1, 10-14, Gauntlet / Short Sleeves 17 + arm(s) + hand 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) 100528 Vest - 2 Long Sleeves 1, 10-14, with Gauntlets 17 +arm(s) + hand(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 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 52032 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 1 2 3 4 5 6 7 8 9 25 CT. NO. / OPTIONS 100540 Face Mask 101158 Open Face Mask 100550 Chin Strap 100549 Modified Chin Strap (extends behind ear) 100545 Chin Extension Collar OPTIONS 101165 Nose Covering 101166 Lip Covering QTY. Scoop Neck PRICE ECH
CUSTOM SEMED - LOWER EXTREMITIES 26 LEG CIRCUMFERENCES LEG CIRCUMFERENCES PLETS TPE# -7 1 /2-6 -4 1 /2-3 -1 1 /2 HEEL 0 +1 1 /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 100105 nklet 100101 Knee Length 100201 Thigh Length Waist High: Check ox #22 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 +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.) 28 FOOT MESUREMENTS Colors 100158 lack 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) 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 Silicone and 100176 Contracture Seam 101163 Velcro Tabs 100160 2 Silicone Elastic LENGTH LTERL (outside) SPECT (standard) MEDIL (inside) SPECT IN ODY ONLY (begins at top) ZIPPER OPTIONS LOCTION LENGTH MRK ( ) IN INCHES 52032 R3-5 - Please enter comments on page 6 29
FX YOUR ORDER FORM rightlife Direct: 1-202-895-6948 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 1-800-537-1063. 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. 5825 Carnegie lvd., Charlotte, NC 28209-4633 PO ox 471048, Charlotte, NC 28247-1048 U.S.. To order toll free Tel. Fax for international use: www.jobst.com 52032 R3 = registered trademark - 6-2003 SN-JOST, Inc. Printed in U.S. Rev. 2/03