JOBST® UlcerCARE Custom Fit Compression ... - BSN medical

JOBST ® UlcerCARE
Custom Fit Compression
System Order Form
FAX ORDER TO CUSTOMER SERVICES ON:
0845 122 3450
Knee high (AD) liner *
Date:
Patient Name:
Measured By:
Delivery Address:
Invoice Address:
Knee high (AD) with zipper *
Hospital Purchase Order Number:
Date of Birth:
The Schema-no. is important for Telephone Number:
reordering the same garment.
In this case please ensure that patient
measurements have not changed.
c = circumference for left leg
l = length for left and right leg
c = circumference for right leg
Circumference (c)
Length (l)
left
right
left
right
left
right
The following measurements are needed for
1. Quantity
Quantity
1. Quantityboth liner and zipper Quantity stocking:
cD: Measure circumference two finger
widths below the kneecap, at the
tibial tuberosity
2. Colour
Colour
2. Colour
Colour
cC: measure circumference at greatest calf
Caramel Caramel Caramel circumference Caramel
Black
Black
cB 1 : Approx. 8–10 cm above B, Achilles
Black tendon/calf transition, Black measure
circumference
Liners Please are make packed sure that in you boxes have defined of 2. Quantity
cB: measure circumference at the narrowest
Please and Colour order for in both multiples the liner and of the 2. zipper stocking 3. Zipper point of the leg, Zipper just above the ankle
as well as the position for the zipper.
cY: With maximal dorsiflexion measure
inside (medial) inside (medial)
Note:
circumference around ankle crease
- The liner is available only with closed toe.
or
and heel or
- The zipper stocking is available only with open toe.
cA: foot circumference for slant and
outside(lateral) outside(lateral)
For the foot ending you can choose between
straight foot
straight or slant foot.
or
or
Measuring Instructions:
Maximum circumference for the liner stocking:
cB 36cm and cC 60 cm.
anterior (front)
*Combined nominal compression for zipper stocking and liner of 40mmHg at the ankle.
anterior (front)
cD
cC
cB
cB
cY
cA
1
cD
cC
cB
cB
cY
cA
Please take the following
measurements:
lz: total foot length for
the closed toe liner.
lA: lateral foot length
for the straight foot
of the open toe
zipper stocking only.
lA lateral: foot length
lA medial: foot length for
the slant foot of the
open toe zipper version.
1
Closed toe: lz
Straight foot: lA
Slant foot: lA medial
lateral
lz
lA
lA lateral
medial
lD
la-D
la-C
la-B
la-B
The following measurements are needed for
both liner and zipper stocking:
la-D: Measure length from heel to point D
la-C: Measure length from heel to point C
a
la-B: 1 Measure length from heel to point B 1
la-B: Measure length from heel to point B
lz
lA
lA medial
lA lateral
medial
lateral
1
TA/UCCFOP/000772/0310
Customer Services telephone: 0845 122 3600
E-mail: vascular.uk@bsnmedical.com

JOBST ® UlcerCARE
Custom Fit Compression
System Order Form
FAX ORDER TO CUSTOMER SERVICES ON:
0845 122 3450
Date:
Patient Name:
Measured By:
Delivery Address:
Invoice Address:
Hospital Purchase Order Number:
Date of Birth:
Telephone Number:
Knee high (AD) liner *
Knee high (AD) with zipper *
Circumference (c)
Length (l)
left
right
left
right
left
right
1. Quantity
Quantity
1. Quantity
Quantity
cD
cD
la-D
2. Colour
Colour
2. Colour
Colour
cC
cC
la-C
Caramel Caramel Caramel Caramel
Black
Black
Black
Black
cB
1
cB
1
lD
la-B
1
Liners are packed in boxes of 2.
Please order in multiples of 2.
3. Zipper
inside (medial)
or
outside(lateral)
or
Zipper
inside (medial)
or
outside(lateral)
or
cB
cY
cA
cB
cY
cA
lz
lA
a
la-B
anterior (front)
anterior (front)
Closed toe: lz
lz
Measuring Instructions:
Maximum circumference for the liner stocking:
cB 36cm and cC 60 cm.
*Combined nominal compression for zipper stocking and liner of 40mmHg at the ankle.
Straight foot: lA
Slant foot: lA medial
lateral
lA lateral
medial
lA
lA medial
lA lateral
medial
lateral
TA/UCCFOP/000772/0310
Customer Services telephone: 0845 122 3600
E-mail: vascular.uk@bsnmedical.com