lower extremity measuring & order form: custom-made flat-knit · patient name _____ medi usa...

sensoo*

(CCLII)

with fly

*NOT AVAILABLE IN mediven® sensoo

Stocking material full compression

Needed for all thigh high stockings

Location _________________________

Patient name ____________________________________________________

med

i USA

• 64

81 F

ranz

War

ner P

arkw

ay •

Whi

tset

t, N

C 27

377

• Pho

ne 1-

800-

633-

6334

P024

0Rev

E

Y to D Y to G B to D B to G

GUSSET:

____ Tricot (standard)

____ Netting

____ Compressive

LEVAPAD

SUSPENSORY:

____ Tricot

____ Netting

____ Compressive

Width ______ cm

Length _____ cm

Add 1 cm to cY measurement per pad.

PermanentPermanent

RemoveableRemoveable

Anterior B to C (5cm wide x 8cm high)Posterior C to D (5cm wide x 8 cm high)Lateral C to D (15cm wide x 5 cm high)

SILICONE PIECES CALF STYLES:Left

Right

Pair

Thigh highKnee highWaist highOne leg Waist high*

None

THIGH/WAIST STYLES

PAD

Cherry-Red* Moss-Green*

New Design Elements:* 550 only

Caramel Black Sand

* Trend colors require an extra five days for delivery.

Cashmere*Anthracite*Navy* Magenta* Aqua*

LOWER EXTREMITY MEASURING & ORDER FORM: CUSTOM-MADE FLAT-KNITFax order: 1-800-879-2135 email: customs@mediusa.com

Patient name ____________________________________________________

med

i USA

• 64

81 F

ranz

War

ner P

arkw

ay •

Whi

tset

t, N

C 27

377

• Pho

ne 1-

800-

633-

6334

(contour)

pubic bone

BACK

l K2

l E1

P024

0Rev

E

LENGTHS (landmarks to floor)