ORDER FORM
Sales@BiaCare.com • P: 866.931.0876 • F: 866.931.0052
PO#:
Company:
Phone:
Contact:
Patient Name:
Date:
Age:
Ht:
Wt:
Bill-To Name & Address:
Ship-To Name & Address:
PRODUCT INFORMATION
ITEM NUMBER
COLOR
ACCESSORIES (additional cost)
BLACK
WHITE
SIZE
CHIPPAD HALF (breast to under arm)
CHIPPAD FULL (breast to spine)
DRAINAGE TUBE POCKET
SIZING & ITEM NUMBERS
STEP 1
STEP 2
Measure the circumference at the fullest
part of bust.
Measure the circumference in inches directly
under the bust (where
a regular bra sits).
BUST SIZE
BAND SIZE
STEP 3
Determine the Cup Size: subtract the Band from the Bust.
CUP SIZE
SMALL
MEDIUM
LARGE
BAND SIZE
28 / 30
32 / 34
36 / 38
40 / 42
44 / 46
A/B
2901-AB
2902-AB
2903-AB
2904-AB
2905-AB
C/D
2901-CD
2902-CD
2903-CD
2904-CD
2905-CD
DD/DDD
2901-DD
2902-DD
2903-DD
2904-DD
2905-DD
2” or less = A/B
2” - 4” = C/D
4” - 6” = DD/DDD
XLARGE XXLARGE
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