FACIAL/NECK PAD
P: 866.931.0876
F: 866.931.0052
[email protected]
ORDER FORM
PO#:
Date:
Company:
Phone:
Contact Name:
Patient Name:
Sex:
Age:
Ht:
Wt:
Bill-To Name & Address:
Ship-To Name & Address:
PRODUCT INFORMATION
SIZE:
SMALL
MEDIUM
ACCESSORIES (additional cost):
LARGE
X - LARGE
PAD:
Neck/Mandible
Neck/Cranial
Velcro extender (5cm additional circumferential range) Qty:
SIZING CHART
Head Circumference
Neck Circumference
SMALL
53 - 56
MEDIUM
56 - 58
LARGE
58 - 61
X - LARGE
61 - 64
28 - 33
33 - 38
38 - 43
43 - 58
Head Circumference
(measure 1/2” above eye brow)
Neck Circumference
(measure at largest part of neck)
34