222 Defiance Elbow 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® ELBOW 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 : _________________________________________________________________ City: SHIPPING INFORMATION: ________________________________________ Zip: ____________
FOR ENOVIS USE ONLY:
Order #:______________________________________________________________
Brace #:
______________________________________________________________
Please note that this product is custom-made and therefore the brace is not returnable
NON-METALLIC COLORS:
Step 3
PATIENT INFORMATION:
❏ Black
❏ ❏ ❏ ❏ ❏
❏ ❏ ❏ ❏ ❏
❏ ❏ ❏ ❏ ❏
Seafoam Emerald
True Red Fuchsia Crimson
Bright Blue
❏ ❏ ❏ ❏ ❏
Black Matte
Cotton Candy
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 __________________________________________________ _________________________________________________________________
Smoke Matte Volt
Olive Drab Green Matte Flat Dark Earth Matte
White Navy
Bumble
Grape Velvet
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
Step 1
MULTIPLE COLORS:
Thigh Frame: ____________________________________________________________ Calf Frame: ______________________________________________________________ Fade (not available for matte colors): ❏ Yes ❏ No
cm Standard Short Bicep (32 cm – 97 cm)
Elbow Width
GRAPHICS (extra charge / not available in matte colors):
❏ Stars & Stripes (non-metallic)
❏ Stars & Stripes (metallic)
Lateral Offset
FEATURES:
Step 4
❏ Suede Liners/Pads ❏ Chamois Liners/Pads ❏ Swiveling Strap Tabs ❏ Metal Caps - PowerCaps (recommended for contact sports) ❏ Reinforced Carbon Composite Frame ❏ Installed Extension Stop: 0° 10° 20° 30° 40° (circle one) ❏ Installed Flexion Stop: 45° 60° 75° 90° (circle one) ❏ Neoprene Suspension Strap Kit
cm Standard Short Forearm (26 cm – 66,5 cm)
PRODUCT SELECTION: CCMI Mark III ™ Frame: ❏ DEFIANCE®
Step 2
❏ Football/Collision
Hinge: ❏ Elbow (CI only) Strapping Sequence: ❏ CI Measurement taken by: ❏ CCMI Mark III
ACCESSORIES (extra charge):
Recommended Football Options – Chamois Liners/Pads – Reinforced Carbon Composite Frame – Metal Caps — Power Caps – Square Strap Ends
❏ High Strength Stainless Steel Gears ❏ Full Extension Lockout Stop ❏ Lycra ® Suspension Sleeve ❏ Neoprene Suspension Sleeve ❏ Sports Brace Cover
❏ Sili-Grip Strap Pad Kit ❏ Condyle Pad Kit
❏ Air Condyle Kit
❏ Floam Condyle Pads
❏ Atrophy Pad Kit
order.nordic@enovis.com
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