 |
 |
Date: | |
|
|
|||
| Patient's Name: | |||
| dx | |||
| age | WT | HT | |
|
Requested Compression: |
Indications: | ||
|
1 moderate compression approx. 25 mm Hg |
|
||
|
2 medium strong compression approx. 35 mm Hg |
|
||
|
3 strong compression approx. 45 mm Hg |
|
||
|
Requested model: |
Compression sleeve with strap
|
Compression sleeve with velcro to bra attachment
|
Compression sleeve, wrist to axilla
|
Hand portion with thumb stub (gauntlet)
|
|
Physician's signature and address: |
Services rendered by: |