Search:
Should it be necessary to illustrate an abnormal measurement in a specific anatomical area,
please click here
.
Check Type Of Measurement
Check Type Of Sleeve
CUSTOM SLEEVE ORDER FORM LOWER EXTREMITY
Inches
Centimeters
4-Chamber
8-Chamber
Full Leg
Half Leg
Pull up Straps
Bilateral w/Duplicate Measurements
1.
Thigh Below Crotch
2.
Mid Thigh
7.
Length of leg from Heel to Crotch
3.
KneeCap
4.
Mid Calf
8.
Length from center of Kneecap to Heel
5.
Ankle
6.
Arch(Instep)
Select type of Pump
Sequential/Gradient-4 Chamber SC-2004
Sequential/Gradient/Calibrated-4 Chamber SC-3004
Sequential/Gradient/Calibrated-8 Chamber SC-3008
Bilateral Adapter Kit - 8 Chamber SC-3008-A
Sequential/Gradient/Calibrated-8 Chamber (SC-3008) with Bilateral Adapter Kit-8 Chamber
None
Customer Acct:
Bill To:
Company Name:
*
First Name:
*
Last Name:
*
Phone:
(
)
-
*
Address:
Address(Cont.):
*
City:
*
State:
*
Zip Code:
Ship To:
Company Name:
*
First Name:
*
Last Name:
*
Phone:
(
)
-
*
Address:
Address(Cont.):
*
City:
*
State:
*
Zip Code:
*
Email:
*
Qty Ordered:
*
Ordered by:
*
P.O. #:
*
Date:
Now
Patient's Name:
*
Authorized Person:
*
Phone #:
(
)
-
Fax:
(
)
-
*
Ship Via:
Gr
P1
PS
P2
3D
FEX
UPS Priority(Early AM)
UPS Priority(End of Day)
UPS 2nd Day(End of Day)
UPS Saver
*
Terms:
Demo
N30
COD
CC
Cons
Special Instructions:
*
Security: