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.