Custom (Made-to-Measure) JoViPak Full Arm Form

Transcription

1 L e n g t h to H to G1 to G to F2 to F1 to F to E to D1 to D Length to Length to tip of middle finger ustom (Made-to-Measure) JoViPak Full Arm Form Lateral Length Wrist to Acromion Lateral Length for coverage of Deltoid Landmark Wrist A G F E D1 D F2 F1 JoViPak, nd Avenue South, Suite 101, Kent, Washington H Measure extended arm in relaxed position, palm up. Measure to G with patient standing and arm hanging down to their side. Measurements Recorded in: Inches entimeters Axilla (measure straight across) Proximal or Upper iceps (optional) Mid iceps (optional) Distal or Widest iceps Least Elbow Widest Forearm Distal Forearm Least Wrist Palm at web space Do not include thumb i r c u m f e r e n c e Trace hand flat, palm down on Hand Tracing Guide and indicate where garment should end on fingers. (see arrows on guide) PATIENT INFORMATION Height Weight Right Arm Left Arm OPTIONS or Reference# Primary Secondary OF/Glov (Stitching between each finger to base of nailbeds) Palm Pad (sewn in) irth Dorsum Pad (sewn in) Zipper (Elbow to Axilla) Zipper (Wrist to Elbow) Snug Fit (⅛ smaller at wrist to ½ at axilla) Not recommended for extra small or small arms Slimline (More channels, less foam) over fingers completely (Standard hand extends to base of nailbeds) over to base of fingers only Low ILD Foam (for fragile skin) JoVi Jacket (Nylon/Spandex) For added compression or as a substitute for bandages hoose JoVi Jacket olor: lack White NOTE: Style samples and fabric/color options are listed on the back of this form. ustom (Made-to-Measure) garments are not returnable. Provide hand tracing for ALL glove orders and note desired finger length. Alterations are billed at $60 per hour. all for quote on garments requiring additional engineering or pattern-making time. with Hand Tracing and standard JoViPak Order Form with Shipping and illing Instructions Include fabric and color choice here if you are NOT faxing the back of this form. Fabric olor

2 ustom (Made-to-Measure) JoViPak Full Arm Options FARI otton/lycra Ivory Royal lue Polartec Power Dry Grey Royal lue uff lack Navy lack Leaf Green Purple Heart Glacier lue White French lue Pink (odor-resistant fiber) Polartec Power Dry Silkweight lue Ridge STYLE SAMPLES H G1 G F2 F1 F E D1 D A UE-A1 UE-AD UE-AE UE-AF UE-AG UE-AG1 UE-AH UE-G1 Special Needs or onsiderations i.e. frozen shoulder or dependent limb etc Note: Anticipate oversize charges for arms with G circumferential measurement over 18 inches or 45.5 centimeters. all for quote on garments requiring additional engineering or pattern-making time. Polartec Power Dry w/ X-Static Fiber Glacier lue Indigo lue Leaf Green or Reference# JoViPak, nd Avenue South, Suite 101, Kent, Washington 98032

3 JoViPak nd Ave S. Suite 101 Kent, WA : (206) Toll Free: 1 (866) info@jovipak.com Order Form ustomer ID# PO# ILL TO usiness Attention ity Zip SHIP TO usiness State heck (Payable to Tri-D orporation) redit ard Exp. / ard# ardholder (print name) Signature ill to Account Visa Masterard American Express Attention PAYMENT INFO ONTAT INFORMATION ity Zip usiness Ground 2nd Day Air SHIPPING: PLEASE SPEIFY State Residential ($5 extra) Next Day Air 3 Day Select *Right or Left Patient Previous JoViPak customer Measured y FAX Order onfirmation to: Name: FAX #: This Form Must Accompany Every Order *Primary or Secondary QTY PRODUT # *R or L SIZE *P or S UNIT PRIE 4/21/07 PRODUT SUTOTAL

4 JoViPak ustom (Made-to-Measure) & Made-to-Order (Left) Hand Tracing Guide A Sketch a dotted line to indicate where garment should end. 8" 7" 6" 5" 4" 3" Place flat hand directly over this guide, palm down with wrist flexion crease over 0" or landmark. Use a black pen or dark pencil to trace around the hand and each finger. 2" 1" 1 inch scale or Reference# JoViPak, nd Avenue South, Suite 101, Kent, Washington " Note: When printing this form from a pdf file, verify that your printer will print at 100%. This will insure scale accuracy.

5 JoViPak ustom (Made-to-Measure) & Made-to-Order (Right) Hand Tracing Guide A Sketch a dotted line to indicate where garment should end. 8" 7" with the ustom (Made-to-Measure) or Made-to-Order Full Arm Form 6" 5" 4" 3" Place flat hand directly over this guide, palm down with wrist flexion crease over 0" or landmark. Use a black pen or dark pencil to trace around the hand and each finger. 2" 1" 1 inch scale Place flexion crease over 0" or landmark or Reference# JoViPak, nd Avenue South, Suite 101, Kent, Washington " Note: When printing this Form from a pdf file, verify that your printer will print at 100%. This will insure scale accuracy.