BiaCare Product Catalog | Page 68

P: 866.931.0876 F: 866.931.0052 LEGASSIST - BK with SHELF 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) LENGTHS ABOVE 0 Advanced - WaveFoam™ Custom MedaBoot™ (additional charge) = Locations measured along lateral aspect of leg. Follow the contour of the limb on all measurements Circumferences: Bottom of Patella LENGTHS BELOW 0 * I have watched the online instruction video for the LegAssist™ custom garment. 55 * 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.