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Check Type of Measurement
Inches
Centimeters
Arm W/shldr
Check Type of Sleeve
4-Chamber
8-Chamber
CUSTOM SLEEVE ORDER FORM UPPER EXTREMITY
9.
Axilla To Fingertips Length
8.
Elbow To Fingertips Length
1.
Axilla
2.
Bicep
3.
Elbow
4.
Forearm
5.
Wrist
6.
Palm
7.
Mid Joint
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:
(
)
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Second part
Third part
*
Address:
Address(Cont.):
*
City:
*
State:
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Zip Code:
Ship To:
Company Name:
*
First Name:
*
Last Name:
*
Phone:
(
)
-
Second part
Third part
*
Address:
Address(Cont.):
*
City:
*
State:
*
Zip Code:
*
Email:
*
Qty Ordered:
*
Ordered by:
*
P.O. #:
*
Date:
Date and time
Now
Patient's Name:
*
Authorized Person:
*
Phone #:
(
)
-
Second part
Third part
Fax:
(
)
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Second part
Third part
*
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:
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Security: