Order Form

 

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Prosthetic Fashions>Order Form

CLICK HERE TO PRINT FAX ORDER FORM

 BEBsport Measurement Form for Transfemoral Amputees

 

                                  THE LUK !!

UNILATERAL                                                     BILATERAL

 

 

A - CIRCUMFERENCE 2"FROM DISTAL END                        

B - LENGTH FROM GROIN TO DISTAL END                  

C - LENGTH FROM WAIST TO DISTAL END      

D - CIRCUMFERENCE FOR HIP                            

E - CIRCUMFERENCE FOR WAIST                       

SPECIFY WITH MARK

 

LEFT               

 

RIGHT            

 

BILATERAL  

LENGTH

Bikini            

 

Boxer            

 

Biker              

 

 

SPECIFY LOCATION OF FLY :                                               LEFT SIDE         

 

                                                                                                      RIGHT SIDE     

 

                                                                                                       NO FLY              

 

PATIENT NAME______________________________

PHONE______________________________________

ADDRESS____________________________________

E-MAIL______________________________________

 

 When ordering from this web site the cost is $150.00  per garment plus shipping and handling

Fax order to Genuine Care Rehab at 405-842-8805

 

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