220 A22 bestillingsseddel
Enovis/DJO Nordic AB Murmansgatan 126 212 25 Malmö Sverige T +46 (0) 40 39 40 00 www.enovis.com
CCMI Mark III ™ A22
CCMI Mark III
Scan and send to: order.nordic@enovis.com Or use QR-code on last page to download interactive pdf-form.
FOR ENOVIS USE ONLY:
BILL TO:
Order #:______________________________________________________________
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 : _________________________________________________________________ City: SHIPPING INFORMATION: ________________________________________ Zip: ____________
______________________________________________________________ Brace #:
PRODUCT SELECTION: CCMI Mark III ™ A 22
Step 2
❏ FourcePoint™ (ACL only)
Step 3
FEATURES FOR A22
❏ Installed Extension Stop: 0° 10° 20° 30° 40° (circle one) ❏ Installed Flexion Stop: 60° 45° 75° 90° (circle one) ❏ Neoprene Suspension Strap Kit
Please note that this product is custom-made and therefore the brace is not returnable
PATIENT INFORMATION:
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 __________________________________________________ _________________________________________________________________
ACCESSORIES (extra charge):
(
❏ A22 Sleeve
❏ S ❏ M ❏ L )
❏ Full Extension Lockout Stop
❏ Armor Impact Guard
❏ Lycra® Suspension Sleeve
❏ Pinch Guard (Calf)
❏ Neoprene Suspension Sleeve
❏ Atrophy Pad Kit
❏ Sports Brace Cover
❏ Air Condyle Kit
❏ A22 Gel Condyle Pads
❏ Anti-Migration Strap
A22 MEASUREMENTS
Step 1
in Standard Thigh* (15 ½" –29")
Lateral Offset
Knee Width
in Standard Calf** (12" –19 ½")
For optimal fit, standard calf measurement tape should fall at or above the center of the gastroc.
*Only available in standard thigh **Record only standard calf measurements (actual calf cuff length is a hybrid between short and standard)
order.nordic@enovis.com
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