ROAM OA bestillingsseddel 221
Enovis/DJO Nordic AB Murmansgatan 126 212 25 Malmö Sverige T +46 (0) 40 39 40 00 www.enovis.com
BILL TO:
CCMI Mark III ™ ROAM OA™
Account Name:________________________________________________________ Account #:____________________________ P.O. #:________________________ C o n t a c t :_______________________ P h o n e : ____________________ E x t . ________ A d d r e s s : ________________________________________________________________________ City: __________________________ _______________ Zip: _____________ ❏ Same as “BILL TO” Name: ________________________________________________________________ A d d r e s s : ________________________________________________________________________ City: __________________________ State: _______________ Zip:_____________ SHIPPING INFORMATION: State:
Scan and send to: order.nordic@enovis.com Or use QR-code on last page to download interactive pdf-form.
FOR ENOVIS™ USE ONLY:
Order #:______________________________________________________________ Brace #:______________________________________________________________
PATIENT INFORMATION:
Name: ________________________________________________________________
PRODUCT SELECTION:
A g e : _________________________ H e i g h t : ___________ We i g h t : _____________
Select either one extension or flexion stop.
Knee Measurement:
❏ Right
❏ Left
❏ Reverse
Installed Extension Stop:
❏ New Brace
❏ Remeasurement/Repair
❏ Refurbish
0°
10°
20°
30°
45°
(circle one)
Old Brace #:
__________________________________________________________
Installed Flexion Stop:
75°
20°
30°
45°
60°
90°
(circle one)
OA Affected Compartment: ❏ Medial ❏ Lateral
ACCESSORIES (extra charge):
ROAM OA™ MEASUREMENTS
❏ Strap Replacement – Thigh & Calf Stability Straps with Strap Ends – Central Harness – Thigh & Calf Posterior Load Straps – Thigh & Calf Y-bracket Assemblies – Thigh & Calf Strap Pads with Silicone Grip ❏ Liner Replacement – Thigh Liner – Calf Liner – Condyle Liner
————— 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)
Name/Credentials of supervising HCP:
Measured by: Signature:
Date:
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