[email protected] • P: 866.931.0876 • F: 866.931.0052
PO#:
CUSTOM ORDER FORM
Company:
Phone:
Contact:
Age:
Patient Name:
Ht:
Wt:
Bill-To Name & Address:
Ship-To Name & Address:
I have read and understand the written measuring instructions for the LegAssist™ custom garment.
I have signed and attached the “Custom Order Terms & Conditions” form
I have emailed digital photos to: [email protected]
PRODUCT INFORMATION
LEG
SIZE*
FOAM
FOOT OPTIONS
OPTIONAL
LEFT
REGULAR
FLAT FOAM
COMPREBOOT PLUS (included)
STRAPS OVER KNEE
RIGHT
SUPER
WAVEFOAM™
CUSTOM MEDABOOT™ (additional charge)
HIP ATTACHMENT
™
*NOTE: If the greatest
circumference measurement
is > 90cm order a Super.
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