EZ Custom Measurement Form for Flat Knit Stockings Phone: 1 800 222-4999 Fax: 1 800 645-2519 Account Information Account Number Date Account Name Contact Ship to Address Phone Fax Patient ID P.O. Number Please Select 18-21 mmHg 23-32 mmHg 34-46 mmHg 50 + mmHg Expert (Helastic) Expert (Helastic) Cotton Strong Expert (Helastic) Silver StrongSilver  3022  3021  3021CO  3022CO  3052  3021SV  3022SV  3051SV  3052SV      3023 3023CO 3053 3023SV 3053SV  3024  3054  3024SV  3054SV Re-order #: Prescribing Physician Order Information Quantity:  Pair Extremity:  Right  Left  Both (Expert Cotton, Expert Silver, Strong Silver and all 50+ mmHg garments available in beige) Compression Knee-High & Thigh-High  Straight top border (standard Expert & Strong) left Lengths All lengths taken on the medial side of the leg left right ..... . . . . . . . . . . cG cG. . . . . . . . . . . . . . . l T . . . . . . . . . . . . . . . . . . . . . . . ...... . . . . . . . . . . cF cF. . . . . . . . . . . . . . . . ...... . . . . . . . . . . cE cE. . . . . . . . . . . . . . . . . l G/ l K . . . . . . . . . . . . . . . . . . . . lH . . . . . . . . . . . . . . . . . . . . . . . ... .  Straight top border (standard Expert) right cK. . . . . . . . . . . . . .  AG KT Back cH. . . . . . . . . . . . . ...  Slant top border KT Front cT. . . . . . . . . . . . .  Piece(s) Colors:  Beige  Black  Chestnut  Blue  Dark Blue  Gray  Red  AD  High Rise Back Circumference Measurements ...... . . . . . . . . . . . cD . . . . . .cD. . . . . . . . . . . . . . . . . . l F . . . . . . . . . . . . . . . . . . . . . . .  Silicone border  Hip Attachment (thigh-high)  Left  Right  Worn as one (need T circumference) ...... . . . . . . . . . cC. . . . ...  Knee darts (Typically not required for Expert (3020) ...... . . . . . . . . . cB Compression Pantyhose ...... . . . . . . . . . . . . cY ..... ...... . . . cA  Slant top border (standard Strong) .  Open toe  Closed toe  Slant toe (standard Strong) l Z Full Foot ............ ........... Silver Comfort Patch PCSZ-01-22c lZ ............ ........... l A right medial ............ l A right lateral . . . . . . . . . . . . l A left medial ............ l A left lateral . . . . . . . . . . . . For more flat knit options, please go to www.juzousa.com/dealer for the advanced custom form lC . . . . . . . . . . . . . . . . . . . . . . . . . cY. . . . . . . . . . . . . . . . . . ...... l B1 . . . . . . . . . . . . . . . . . . . . . . . cA. . . . . . . . . . lB . . . . . . . . . . . . . . . . . . . . . . . lA l A Open Toe Slant Toe - required measurements  Behind the knee  Crease of ankle and top of foot lD . . . . . . . . . . . . . . . . . . . . . . . ... . ... .. lA lZ cB. . . . . . . . . . . . . . . . lE . . . . . . . . . . . . . . . . . . . . . . . ... ... Foot Portion .. .  AT  Knee darts (Typically not required for Expert (3020) cB.1 . . . . . . . . . . . . . . . . ... ... ..... . . . . . . . . . . . cB 1 .cC. . . . . . . . . . . . . . . . . Special requests: