CUSTOM SLEEVE ORDER FORM LOWER EXTREMITY

Please fill in all appropriate information. Once complete, please print & fax to 201-939-0716 or 201-438-1006.

Check Type Of Measurement	Check Type Of Sleeve
InchesCentimeters	4-Chamber8-Chamber
Full LegHalf Leg	Left LegRight 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
None

Customer Account

Billing Information

Company Name
First Name
Last Name
Phone
Address
Address(Cont.)
City
State
Zip Code

Shipping Information

Company Name
First Name
Last Name
Phone
Address
Address(Cont.)
City
State
Zip Code

Order Information

Email
Qty Ordered
Ordered By
P.O.#
Patient's Name
Date
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	DemoN30CODCCCons
Special Intructions

Fax: 201-939-4503 or 201-438-1006