lower extremity measuring & order form: custom-made flat-knit · patient name _____ medi usa...
TRANSCRIPT
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: [email protected]
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)