BiaCare Product Catalog | Page 65

LEGASSIST™ - BK P: 866.931.0876 F: 866.931.0052 Measure & Order Form [email protected] PO#: Date: Company: Phone: Contact Name: Patient: Sex: Age: Ht: Wt: Bill-To Name & Address: Ship-To Name & Address: PRODUCT OPTIONS SIDE: Left Right FOOT OPTIONS: FOAM: Regular - Flat foam CompreBoot™ PLUS (included) Advanced - WaveFoam™ Custom MedaBoot™ (additional charge) Bottom of Patella Ankle Bend I have watched the online instruction video for the LegAssist™ custom garment. I have read and understand the written measuring instructions for the LegAssist™ custom garment. Photos have been emailed to: [email protected] Orders will not be accepted without all three boxes being checked. Your assistance in this will help the patient receive a better product in less time. 52