1. No category

Account Number: 1014233
(example PT/OT/PTA)
Date:
Neck and Chin Bandage
Closure Options
Hook and loop
Custom Measurement Form
for Compression Face Mask
Hook and eye
Opening for Ears
yes
no
Width . . . . . . . . . cm
Height . . . . . . . . . cm
Circumferences
Prescribing Physician
Quantity................................. piece(s)
Juzo® Expert (Helastic)
Beige
Red
Dark Blue
Blue
Gray
Chestnut
Black
Compression
18-21 mmHg
.......... cE1
3021
.......... cE
Juzo® Expert (Helastic) Silver
EE1
3021SV
Length of the Neck Part
(measured in the front of the neck)
AB
cm
BC
cm
CD
cm
DE
Length of the Headband
(measured from “D1” over the head to the same
point on the opposite side)
D1
.......... cD
D1 D1
cm
.......... cC
CD
BC
.......... cB
Neck and Chin Bandage
AB
.......... cA
Face Mask
Forehead and back of head
EE1
Openings for:
closed
nose
mouth
cm
eyes
Nose portion knitted according to measurements: M1 =
M2 =
Special Request:
open
cm
cm
Width and Length Measurements
K = . . . . . . . cm
M = . . . . . . . cm
N = . . . . . . . cm
P = . . . . . . . cm
P
U
M2
N
M1
S
M
T
S = . . . . . . . cm
T = . . . . . . . cm
K
U = . . . . . . . cm
Luna Medical, Inc. · Specialists in Venous & Lymphatic Insufficiencies
1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com