Sales@BiaCare.com • P: 866.931.0876 • F: 866.931.0052
PO#:
Company:
Phone:
ORDER FORM
Contact:
Date:
Patient Name:
Age:
Ht:
Wt:
Bill-To Name & Address:
Ship-To Name & Address:
PRODUCT INFORMATION
ARM
LEFT
RIGHT
CUSTOM OVERSLEEVE (included):
Note: if no color is specified, a black
OverSleeve™ will be included.
Black
Pink
Leopard
Navy
Tie-Dye
Blue Horizon
MEASURING INSTRUCTIONS
With patient seated, place the arm extended and elbow bent slightly,
with the palm down, on a flat surface.
CIRCUMFERENCES
Measure circumference at Palm and record on line E.
Measure at Wrist, and record on line A.
Mark dorsal aspect at distal edge of tape.
Measure at Forearm, and record on line A1.
Measure at Elbow, and record on line B.
Measure at mid Bicep, and record on line B1.
Measure at Axilla,