_BiaCare_Catalog | Page 18

ARMASSIST ™

P: 866.931.0876
F: 866.931.0052

Measure & Order Form

[e-mail]

PO/Estimate#:

Date:

Company:
Phone:

Contact Name:
Patient:

Sex:

Age:

Ht:

Wt:

Bill-To Name & Address:
Ship-To Name & Address:

MEASURING INSTRUCTION OPTIONS
CATALOG: Page 59 for ArmAssist™
custom Arm measuring instructions.

WEB: Scan QR code

EMAIL: [e-mail]

OR visit BiaCare.com

I have read and understand the written measuring
instructions for the ArmAssist™ custom garment.

I have watched the online instruction video
for the ArmAssist™ custom garment.

Photos have been emailed to:
[e-mail]

Orders will not be accepted without all three boxes being checked. Your assistance in this will help the patient receive a
better product in less time.

PRODUCT OPTIONS
ARM: Left
Right

FOAM:

BiaCare.com

Regular (flat foam)

•

P: 866.931.0876

Advanced (WaveFoam™)

•

F:866.931.0052

12