Defiance Classic bestillingsseddel 219
Enovis/DJO Nordic AB Murmansgatan 126 212 25 Malmö Sverige T +46 (0) 40 39 40 00 www.enovis.com CCMI Mark III ™ DEFIANCE® CLASSIC 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: _____________________ A d d r e s s : _________________________________________________________________ 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 4
Please note that this product is custom-made and therefore the brace is not returnable
Black
Seafoam
True Red Fuchsia Crimson
Bright Blue
Black Matte Emerald
Cotton Candy
PATIENT INFORMATION:
Smoke Matte Volt
Olive Drab Green Matte Flat Dark Earth Matte
White Navy
Bumble
Grape Velvet
Name: __________________________________________________________ A g e : _____________________ H e i g h t : __________ We i g h t : ____________ Knee Measurement: Right Left Reverse Measured By: ____________________________________________________ New Brace Remeasurement/Repair Comments __________________________________________________ _________________________________________________________________
Safety Orange
Desert Tan Matte
Powder
METALLIC COLORS:
Metallic Black
Metallic White
Metallic Forrest Metallic Gold
Metallic Gunmetal
Metallic Bright Blue
Metallic Silver
Metallic Navy
Metallic Tru Red
MULTIPLE COLORS:
Thigh Frame: ____________________________________________________________ Calf Frame: ______________________________________________________________ Fade (not available for matte colors): Yes No
DEFIANCE® CLASSIC MEASUREMENTS:
Step 1
————— cm Short Thigh
————— in Standard Thigh (12½” – 38£”)
(31.8 cm – 97 cm)
GRAPHICS (not available in matte colors):
Knee Width
Lateral Offset
Stars & Stripes (non-metallic)
Stars & Stripes (metallic)
FEATURES: Suede Liners/Pads Chamois Liners/Pads
Step 5
————— in Standard Calf (10¼” – 26¼”)
————— cm Short Calf
(26.2 cm – 66.5 cm)
Swiveling Strap Tabs Metal Caps - PowerCaps (recommended for contact sports) Reinforced Carbon Composite Frame High Strength Stainless Steel Gears Installed Extension Stop: 0° 10° 20° 30° 40° (circle one) Installed Flexion Stop: 45° 60° 75° 90° (circle one) Legend Straps End
Note: Check both short and standard measurements for ski boot option. Best to measure with Ski Boot On.
PRODUCT SELECTION: CCMI Mark III Frame: Swooping Thigh Hinge: FourcePoint™ (ACL, LCL, MCL)
Step 2
Non-Swooping Thigh
FourcePoint™ Plus
Recommended for contact sports (ACL, LCL, MCL)
Standard (ACL, PCL, MCL, LCL) DropLock (CI only) Strapping: Adjustable OA
ACCESSORIES (extra charge): Full Extension Lockout Stop Lycra® Undergarment Sleeve Neoprene Undergarment Sleeve Sports Brace Cover Sili-Grip Strap Pad Kit FourcePoint Hinge Stop Kit
Gel Condyle Pad
Armor Impact Guard Pinch Guard (Calf) Atrophy Pad Kit Tru-Pull® Advanced Extra set of Liners & Straps
ACL
CI (Combined Instability, best for multi-ligament or PCL)
Step 3
OA Affected Compartment:
Medial Lateral Degrees of Correction:
Air Condyle Pad Supra condylar Pad
Anti-Migration Strap
_________
(1° to 7°)
(Standard = 3°)
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