1. No category

circaid® reduction kit order form - lower extremity
Fax Orders: 1-888-570-4554
Email: [email protected]
Customer Name
Customer No.
Billing Address
Patient Name
Shipping Address
Order Date
Telephone
Fax
Purchase Order No.
Email
Measured By
Shipping Method
Credit Card Info
upper leg kit: Check the box next to the corresponding length and width.
*cG cannot be more than 30cm larger than cE2.
left
right
Short
cG
l knee crease - groin
left
right
Left l KC-Groin
Right < 37cm
Each upper leg
kit includes:
Length
Standard
l KC-Groin
37 - 41cm
Width
Regular
Wide
cG< 80cm
cE2< 65cm
l KC-Groin
> 41
Quantity
cG< 125cm
cE2< 110cm
• 1 reduction upper leg component • 1 Built-In-Tension system guide card
• 1 reduction shelf strap
• 1 paper measuring tape
• 6 Velcro® stays
• 1 direction for use.
knee kit:
(the reduction knee kit is only avalaible in one length and width)
*cE2 cannot be more than 30cm larger than cC.
Length
Left
Each knee kit includes:
right
cE
left
right
right
l mall - knee crease
left
Quantity
• 1 reduction knee component
• 2 Velcro® knee spines
• 1 paper measuring tape
• 1 direction for use
• 1 reduction shelf strap
lower leg kit:
Check the box next to the corresponding length and width.
*cC cannot be more than 30cm larger than cB.
Length
Standard
Short
cC
Width
cE 2 < 110cm
cE < 102cm
cC < 80cm
30cm
Right
cE2
left
Left
Right
l mall-KC
< 32cm
l mall-KC
32 - 36cm
Width
Long
Regular
cC< 65cm
cB< 55cm
l mall-KC
> 36cm
Wide
Quantity
cC< 80cm
cB< 65cm
Each lower leg
kit includes:
• 1 reduction lower leg component • 1 Built-In-Tension system guide card
• 1 paper measuring tape
• 1 reduction kit undersleeve leg
• 1 direction for use
1 reduction shelf strap
power added compression band™ (pac• band™)
• 6 Velcro® stays
foot options: Check the box next to the corresponding length and width.
* foot options are not included with the kit and must be ordered separately.
compression anklet
cB
left
Standard
right
cH
left
left
Long
right
Left
Right
pac band™
Large
X-Large
Single band AFW®
cH 19-36 cm
cH 22-41 cm
cH < 44cm
cH > 41cm
cB 19-27 cm
cB 25-50 cm
cB < 56cm
cB > 50cm
right
additional ancillary items:
reduction kit undersleeve leg
Quantity (Pairs)
reduction kit shelf strap
Quantity (Each)
mediUSA 6481 Franz Warner Parkway Whitsett, NC 27377 Phone 1-800-633-6334 www.mediusa.com
Quantity
circaid® reduction kit order form - upper extremity
Fax Orders: 1-888-570-4554
Email: [email protected]
Customer Name
Customer No.
Billing Address
Patient Name
Shipping Address
Order Date
Telephone
Fax
Purchase Order No.
Email
Measured By
Shipping Method
Credit Card Info
arm kit: Check the box next to the corresponding length and width.
* If cB is > 25cm hand wrap will not fit, though reduction arm component may still be used.
Length
Standard
Long
Left
Right
right
left
right
cF
l C-G> 45cm
Regular
cF < 50cm
cB < 25cm*
Wide
Quantity
cF 50-80cm
cB < 25cm*
Each arm kit includes:
• 1 reduction arm component
• 1 pair undersleeve arm
• 1 customizable hand wrap
• 1 Built-In-Tension guide card
• 1 paper measuring tape
• 1 direction for use
l C-G
left
l C-G < 45cm
Width
cB
left
right
additional ancillary items:
undersleeve arm standard
Standard <50cm max circ.
Quantity (Each)
undersleeve arm wide
Wide <80cm max circ.
Quantity (Each)
reduction kit shelf strap
Quantity (Each)
mediUSA 6481 Franz Warner Parkway Whitsett, NC 27377 Phone 1-800-633-6334 www.mediusa.com
P1515