P: 866.931.0876
F: 866.931.0052
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ChipVest™
ORDER FORM
PO#:
Date:
Company:
Phone:
Contact Name:
Patient Name:
Sex:
Age:
Ht:
Wt:
Bill-To Name & Address:
Ship-To Name & Address:
CHANNELS
STYLE
FULL (Bilateral)
LEFT SIDE (Unilateral)
RIGHT SIDE (Unilateral)
HORIZONTAL
VERTICAL
LENGTH
SHORT
REGULAR
LONG
XLONG
SIZING CHART
X-SMALL SMALL MEDIUM LARGE X-LARGE XX-LARGE
71 - 81 81 - 91 91 - 101 101 - 111 111 - 121 121 - 131
D
A 52 - 70 62 - 80 72 - 90 82 - 100 92 - 110 102 - 120
A1 76 - 96 86 - 106 96 - 116 106 - 126 116 - 136 126 - 146
Short: 32 - 35
Regular: 35 - 38
Long: 38 - 41
X-Long: 41 - 44
L
MEASURING INSTRUCTIONS
1. Measure the Length from the suprasternal notch
to the waist and record in box L.
2. Measure circumferences at D, A, and A1 and
record in the appropriate boxes.
3. Use charts to determine size/item number.
36