Sales@BiaCare.com • P: 866.931.0876 • F: 866.931.0052
PO#:
Company:
Phone:
Patient Name:
CUSTOM ORDER FORM
Contact:
Age:
Ht:
Wt:
Bill-To Name & Address:
Ship-To Name & Address:
I have read and understand the written measuring instructions for the ArmAssist™ custom garment.
I have signed and attached the “Custom Order Terms & Conditions” form
I have emailed digital photos to: Sales@BiaCare.com
PRODUCT INFORMATION
ARM
FOAM
LEFT
FLAT FOAM
RIGHT
WAVEFOAM™
63