PO#:
Company:
Phone:
CUSTOM
ORDER FORM
Sales@BiaCare.com • P: 866.931.0876 • F: 866.931.0052
Contact:
Date:
Patient Name:
Age:
Ht:
Wt:
Bill-To Name & Address:
Ship-To Name & Address:
PRODUCT INFORMATION
CHANNNELING
ITEM # 2239-VS
FULL (Bilateral)
LEFT SIDE (Unilateral)
RIGHT SIDE (Unilateral)
SIZING & ITEM NUMBERS
1. Measure the Length in centimeters from the Suprasternal Notch to the waist.
2. Measure Circumferences in centimeters.
L
LENGTH:
Suprasternal Notch
to Waist
AXILLA
LARGEST CHEST
XYPHOID PROCESS
WAIST
MID-HIP
21