jovi custom full leg garment measurement form custom...· spec alistsin veno s &lympha ic ins...
TRANSCRIPT
Account Number: 4057807
(example PT/OT/PTA)Date:
Luna Medical, Inc. · Specialists in Venous & Lymphatic Insu ciencies1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com
JOVIPAK CUSTOM FULL LEG GARMENT MEASUREMENT FORM
Black Ivory
Royal Blue
Black
French Blue Glacier Blue
Leaf Green Navy Blue
Pink Plum
Royal Blue Stainless SteelAD AF1 AG AG1 DG1AB1
Black Ivory
Royal Blue
Black
French Blue Glacier Blue
Leaf Green ®)
Navy Blue
Pink Plum
Royal Blue Stainless SteelAD AF1 AG AG1 DG1AB1
N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.comLuna Medical, Inc. · Specialists in Venous & Lymphatic Ins ciencies
1816 W. Belmont Avenue · Suite 1 · Chicago, IL 60657 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com
JoViPak Order FormFAX THIS FORM TOLL FREE TO: 1-877-760-4943 (I NCLUDE RIGHT FOOT TRACING)
Custom Right Leg Garment
Primary or
Yes No
(AD to AG1)
(AD or AG)
- Black White
(Matching fabric with non-slip sole)
(Unpadded sole)
- ankle to knee
(Sewn in)
(Sewn in)
Medial Lateral
on InnaBoot
- donning aid
- donning aid
2 blend (Thin or fragile skin)
Revised 5/1/14
Account Number: 4057807
(example PT/OT/PTA)Date:
Luna Medical, Inc. · Specialists in Venous & Lymphatic Insu ciencies1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com
JOVIPAK CUSTOM RIGHT LEG CARMENT ORDER FORM
N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.comLuna Medical, Inc. · Specialists in Venous & Lymphatic Ins ciencies
1816 W. Belmont Avenue · Suite 1 · Chicago, IL 60657 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com
Custom Right Foot Tracing
Account Number: 4057807
(example PT/OT/PTA)Date:
Luna Medical, Inc. · Specialists in Venous & Lymphatic Insu ciencies1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.comN. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com
Luna Medical, Inc. · Specialists in Venous & Lymphatic Ins ciencies1816 W. Belmont Avenue · Suite 1 · Chicago, IL 60657 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com
N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.comLuna Medical, Inc. · Specialists in Venous & Lymphatic Ins ciencies
1816 W. Belmont Avenue · Suite 1 · Chicago, IL 60657 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com
JoViPak Order FormFAX THIS FORM TOLL FREE TO: 1-877-760-4943 (I NCLUDE LEFT FOOT TRACING)
Custom Left Leg Garment
Primary or
(AD to AG1)
(AD)
(AD)
(AD)
(AD or AG)
Yes No
- Black White
(Matching fabric with non-slip sole)
(Unpadded sole)
- ankle to knee
(Sewn in)
(Sewn in)
Medial Lateral
on InnaBoot
- donning aid
- donning aid
2 blend (Thin or fragile skin)
Revised 5/1/14
Account Number: 4057807
(example PT/OT/PTA)Date:
Luna Medical, Inc. · Specialists in Venous & Lymphatic Insu ciencies1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com
JOVIPAK CUSTOM LEFT LEG CARMENT ORDER FORM
N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.comLuna Medical, Inc. · Specialists in Venous & Lymphatic Ins ciencies
1816 W. Belmont Avenue · Suite 1 · Chicago, IL 60657 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com
Tracing
Account Number: 4057807
(example PT/OT/PTA)Date:
Luna Medical, Inc. · Specialists in Venous & Lymphatic Insu ciencies1360 N. Sandburg Terrace · Suite #103 · Chicago, IL 60610 · Phone (800) 380-4339 · Fax (888) 696-0299 · www.lunamedical.com