LEGASSIST - LOBULE COMPRESSION SYSTEM (LCS)
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
OPTIONAL:
FOAM:
Regular - Flat foam
Advanced - WaveFoam™
Hip Attachment (additional charge)
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.
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