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Check Type of Measurement
Inches
Centimeters
Arm W/shldr
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
None
Customer Acct:
Bill To:
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Company Name:
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First Name:
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Last Name:
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Phone:
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Address:
Address(Cont.):
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City:
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Ship To:
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Company Name:
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First Name:
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Last Name:
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Phone:
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Address:
Address(Cont.):
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City:
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Zip Code:
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Email:
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Qty Ordered:
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Ordered by:
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P.O. #:
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Date:
Now
Patient's Name:
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Authorized Person:
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Phone #:
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Fax:
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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
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Terms:
Demo
N30
COD
CC
Cons
Special Instructions:
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