JoViPak Custom Hip Hugger Garment Measurement

JoViPak Custom Hip Hugger Garment Measurement

Account Number: 4057807
(example PT/OT/PTA)
Date:
JOVIPAK CUSTOM HIP HUGGER
GARMENT MEASUREMENT FORM
Hip Hugger Organic
Black
Hip Hugger Combi Organic
Black/Black
Ivory
Royal Blue
Luna
Medical,
· Specialists
in Venous
& Lymphatic
Insufficiencies
Luna
Medical,
Inc.Inc.
· Specialists
in Venous
& Lymphatic
Insufficiencies
N.
Sandburg
Terrace
·
Suite
#103
·
Chicago,
IL
60610
·
Phone
(800)
380-4339
·
Fax
(888)696-0299
696-0299· ·www.lunamedical.com
·www.lunamedical.com
www.lunamedical.com
1816
W.
Belmont
Avenue
·
Suite
1
·
Chicago,
IL
60657
·
Phone
(800)
380-4339
·
Fax
1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax(888)
(888)
696-0299
Account Number: 4057807
(example PT/OT/PTA)
Date: Hip Hugger & Hip Hugger Combi
Custom
JoViPak Order Form
JOVIPAK CUSTOM HIP HUGGER
FAX THIS
FORM TOLL FREE TO: 1-877-760-4943
GARMENT MEASUREMENT
FORM
Yes
No
Height: __________ Weight: __________ Birthdate: __________
(separate)
Black
White
(Matching
fabric with non-slip sole)
- ankle to knee
(Sewn in)
(Sewn in)
Lateral
Medial
(for Hip Hugger only)
Black
White
(Matching
fabric with non-slip sole)
- ankle to knee
(Sewn in)
Medial
(Sewn in)
Lateral
- donning aid
- donning aid
K1 thru G to K2
Luna
Medical,
· Specialists
in Venous
& Lymphatic
Insufficiencies
Luna
Medical,
Inc.Inc.
· Specialists
in Venous
& Lymphatic
Insufficiencies
N.
Sandburg
Terrace
·
Suite
#103
·
Chicago,
IL
60610
·
Phone
(800)
380-4339
·
Fax
(888)696-0299
696-0299· ·www.lunamedical.com
·www.lunamedical.com
www.lunamedical.com
1816
W.
Belmont
Avenue
·
Suite
1
·
Chicago,
IL
60657
·
Phone
(800)
380-4339
·
Fax
1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax(888)
(888)
696-0299
Account Number: 4057807
(example PT/OT/PTA)
Date:
Custom Right Foot
Tracing
Luna
Medical,
· Specialists
in Venous
& Lymphatic
Insufficiencies
Luna
Medical,
Inc.Inc.
· Specialists
in Venous
& Lymphatic
Insufficiencies
N.
Sandburg
Terrace
·
Suite
#103
·
Chicago,
IL
60610
·
Phone
(800)
380-4339
·
Fax
(888)696-0299
696-0299· ·www.lunamedical.com
·www.lunamedical.com
www.lunamedical.com
1816
W.
Belmont
Avenue
·
Suite
1
·
Chicago,
IL
60657
·
Phone
(800)
380-4339
·
Fax
1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax(888)
(888)
696-0299
Account Number: 4057807
Custom Hip Hugger & Hip Hugger
Combi
(example
PT/OT/PTA)
Date:
JoViPak Order Form
JOVIPAK CUSTOM HIP HUGGER
FAX THIS FORM TOLL FREE TO: 1-877-760-4943
GARMENT MEASUREMENT FORM
Yes
No
Height: __________ Weight: __________ Birthdate: __________
(separate)
Black
White
(Matching
fabric with non-slip sole)
- ankle to knee
(Sewn in)
(Sewn in)
Lateral
Medial
(for Hip Hugger only)
Black
White
(Matching
fabric with non-slip sole)
- ankle to knee
(Sewn in)
(Sewn in)
Lateral
Medial
- donning aid
- donning aid
K1 thru G to K2
Luna
Medical,
· Specialists
in Venous
& Lymphatic
Insufficiencies
Luna
Medical,
Inc.Inc.
· Specialists
in Venous
& Lymphatic
Insufficiencies
N.
Sandburg
Terrace
·
Suite
#103
·
Chicago,
IL
60610
·
Phone
(800)
380-4339
·
Fax
(888)696-0299
696-0299· ·www.lunamedical.com
·www.lunamedical.com
www.lunamedical.com
1816
W.
Belmont
Avenue
·
Suite
1
·
Chicago,
IL
60657
·
Phone
(800)
380-4339
·
Fax
1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339
· Fax(888)
(888)
696-0299
Phone:
Revised 5/21/14
Account Number: 4057807
(example PT/OT/PTA)
Date:
Tracing
Luna
Medical,
· Specialists
in Venous
& Lymphatic
Insufficiencies
Luna
Medical,
Inc.Inc.
· Specialists
in Venous
& Lymphatic
Insufficiencies
N.
Sandburg
Terrace
·
Suite
#103
·
Chicago,
IL
60610
·
Phone
(800)
380-4339
·
Fax
(888)696-0299
696-0299· ·www.lunamedical.com
·www.lunamedical.com
www.lunamedical.com
1816
W.
Belmont
Avenue
·
Suite
1
·
Chicago,
IL
60657
·
Phone
(800)
380-4339
·
Fax
1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax(888)
(888)
696-0299