Lower Extremity

LOWER EXTREMITY MEASURING & ORDER FORM: CUSTOM-MADE FLAT-KNIT
medi USA • 6481 Franz Warner Parkway • Whitsett, NC 27377 • Phone 1-800-633-6334
Fax order: 1-800-879-2135 email: [email protected]
Patient name ____________________________________________________
Stocking material full compression
(CCLII)
Knee high
Waist high
One leg Waist high*
Thigh high
Needed for all thigh high stockings
with fly
GUSSET:
SUSPENSORY:
____ Tricot (standard)
____ Tricot
____ Netting
____ Netting
____ Compressive
____ Compressive
None
Width ______ cm
Length _____ cm
THIGH/WAIST STYLES
* 550 only
Right
Location _________________________
SILICONE PIECES CALF STYLES:
Anterior B to C (5cm wide x 8cm high)
LEVAPAD
Posterior C to D (5cm wide x 8 cm high)
Lateral C to D (15cm wide x 5 cm high)
Pair
Caramel
Black
Navy*
Magenta*
*NOT AVAILABLE IN mediven® sensoo
Sand
Aqua*
Cherry-Red*
*
Anthracite*
Y to D
Y to G
Moss-Green*
Cashmere*
* Trend colors require an extra five days for delivery.
B to D
B to G
sensoo
PAD
Add 1 cm to cY measurement per pad.
Permanent
Permanent
Removeable
Removeable
P0240RevE
New
Design
Elements:
Left
(landmarks to floor)
pubic bone
BACK
l K2
l E1
(contour)
medi USA • 6481 Franz Warner Parkway • Whitsett, NC 27377 • Phone 1-800-633-6334
LENGTHS
P0240RevE
Patient name ____________________________________________________