JOBST® Elvarex® Custom-Fit Lower Limb Order Form

JOBST® Elvarex® Custom-Fit
Lower Limb Order Form
Date:
FAX ORDER TO CUSTOMER SERVICES ON:
Purchase Order No.:
Patient Name:
DoB:
Measured By:
Tel:
Email:
Delivery Address:
Invoice Address:
0845 122 3450
CompressionQuantity
Class
Left
Right
Body Bandage
CCL1 (18-21mmHg)
CCL2 (23-32mmHg)
CCL3 (34-46mmHg)
Left Leg
Length
Measurements
Left Leg
Right Leg
(cms)
CCL3F (34-46mmHg)
CCL4 (49-70mmHg)
CCL4S (60-90mmHg)
Colour:
JOBST Elvarex Soft
Circumference Measurements (cms)
Options:
BeigeBlack Body bandage
Adjustable waistband
Dark Blue
Dark Brown
Fly for men
Grey
Crotch for men
Style:
Open pubis
Re-inforced gusset
AD Knee high
Slipform
AG Thigh high
Silicone band
AGTL Waist attachment left
2.5cm
5cm
AGTR Waist attachment right
Inside
Top
AG-T Waist attachment pair
Silicone pieces
AT Tights
3/4 Silicone band
AT Tights 1 leg
Zipper with lining†
AF Mid thigh*
Silk pocket†
T-Heel (CCL 2-3F only)
Ankle pad (profile)
Top functional zone*
Knee functional zone*
(CCL 2-4S only)
* not available on FP10 / GP10
Compression Class:
Right Leg
Length
Measurements
(cms)
a-K
a-K
(crotch length for AT
and all Top Functional
Zone orders)
(crotch length for AT
and all Top Functional
Zone orders)
a-G
a-G
a-F
a-F
a-E
a-E
a-D
(Knee high)
D
D
a-D
(Knee high)
a-C
a-C
a-B1
a-B1
a-B
a-B
Remarks:
*a = floor/base of measuring board
Foot Styles
Open toe
Slant foot
†
State position/length
Closed toe
Foot Length
For open toe
Lengths for slant foot
Length medial
Straight foot
For closed toe
Length lateral
(applicable length measurements required)
CCL1 (18-21mmHg)
CCL2 (23-32mmHg)
CCL3 (34-46mmHg)
Colour:
Beige
Black
Style:
AD Knee high
AG Thigh high (with slip form)
AGTL Waist attachment left
AGTR Waist attachment right
AG-T Waist attachment pair
AT Tights (with slip form)
Quantity:
Left
AT Tights
Right
Options:
Adjustable waistband
Open pubis
Silicone dotted band 2.5cm on top (A-D only)
5.0cm on top
Silk Pocket†
T-Heel
Remarks:
(longest toe)
Steps: 1. Complete order box for EITHER JOBST Elvarex or JOBST Elvarex Soft. 2. Select garment style required. 3. Complete ALL applicable measurement boxes. 4. Fax order.
Customer Service: 0845 122 3600 Compression Therapy Helpline: 0800 389 8424 Email: [email protected] www.bsnmedical.co.uk
†
State position/length
0391/514
JOBST Elvarex

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