218 Defiance PRO bestillingsseddel
Enovis/DJO Nordic AB Murmansgatan 126 212 25 Malmö Sverige T +46 (0) 40 39 40 00 www.enovis.com CCMI Mark III ™ DEFIANCE® PRO Scan and send to: order.nordic@enovis.com Or use QR-code on last page to download interactive pdf-form.
BILL TO:
Account Name: __________________________________________________ Contact: _________________________ Phone: _____________________ Address: _________________________________________________________________ City: ________________________________________ Zip: ____________ Same as “BILL TO” Name: __________________________________________________________ A d d r e s s : _________________________________________________________________ SHIPPING INFORMATION:
FOR ENOVIS USE ONLY:
Order #: _________________________________________________________ Brace #: _________________________________________________________
City:
________________________________________
Z i p : ____________
NON-METALLIC COLORS:
Step 3
Please note that this product is custom-made and therefore the brace is not returnable
Fuchsia Grape Velvet True Red Crimson
Black
Seafoam Emerald
Bright Blue
PATIENT INFORMATION:
Black Matte
Cotton Candy
Smoke Matte Volt
Olive Drab Green Matte Flat Dark Earth Matte
Name: __________________________________________________________ A g e : _____________________ H e i g h t : __________ We i g h t : ____________ Knee Measurement: Right Left Reverse Measured By: ____________________________________________________ Remeasurement/Repair Comments: __________________________________________________ _________________________________________________________________ New Brace
White Navy
Bumble
Safety Orange
Desert Tan Matte
Powder
METALLIC COLORS:
Metallic Black
Metallic White
Metallic Forrest
Metallic Gunmetal
Metallic Bright Blue
Metallic Gold
Metallic Silver
Metallic Navy
Metallic Tru Red
MULTIPLE COLORS:
DEFIANCE® PRO MEASUREMENTS:
Step 1
Step 4 DEFAULT – PLEASE NOTE: • Sili-grip strap pads • Silicone pads with Fource Point, Standard, Droplock & FourcePoint Plus hinge • Memory Foam with OA hinge Thigh Frame: ____________________________________________________________ Calf Frame: ______________________________________________________________ Fade (not available for matte colors): Yes No
————— cm Short Thigh
————— in Standard Thigh (12½” – 38¦”)
(31.8 cm – 97 cm)
Knee Width
Lateral Offset
————— in Standard Calf (10¼” – 26¾”)
————— cm Short Calf
(26.2 cm – 67.9 cm)
FEATURES: Reinforced Carbon Composite Frame
Step 5
Note: Check both short and standard measurements for ski boot option. Best to measure with Ski Boot On.
DEFIANCE® PRO PRODUCT SELECTION:
Step 2
High Strength Stainless Steel Gears
Note: Pro includes only Swoop Thigh for standard thigh length. (Swoop not available on short thigh length) and internally mounted straps.
Installed Extension Stop:
0°
10°
20° 30° 40° (circle one)
Hinge: FourcePoint™ (ACL, LCL, MCL) Standard (ACL, PCL, MCL, LCL)
Installed Flexion Stop:
45°
60°
75° 90° (circle one)
FourcePoint™ Plus
Recommended for contact sports (ACL, LCL, MCL)
DropLock (CI only) Adjustable OA
ACCESSORIES (extra charge): Condyle Pads
Step 6
Miscellaneous
Condyle Pads:
Silicone Memory Foam Air condyle Surround Gel
Impact Guard Sport Brace Cover Tru-Pull Advanced Anti-migration Band Full Extension Lockout Stop Neoprene Suspension Strap kit
Memory Foam
Silicone (default)
Strapping:
ACL
CI (Combined Instability, best for multi-ligament or PCL)
Strap End Options: Soft Touch (Default except XS – S size range) Legend (Same as previous Defiance)łł
Supra condylar Pad
Sleeve
Lycra Suspension Sleeve Neoprene Suspension Sleeve Compression Knit Sleeve
Extra Liners, Straps, Pads Thigh Softgood kit Calf Softgood kit
OA Affected Compartment:
Medial Lateral Degrees of Correction: _________ (1° to 7°)
(Standard = 3°)
order.nordic@enovis.com
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