Torbot Custom Compression JOBSKIN COMPRESSION GARMENT
Transcript of Torbot Custom Compression JOBSKIN COMPRESSION GARMENT
NOTE: DO NOT SEND MEASURING TAPES IF PATIENT HAS INFECTIOUS DISEASE OR IF TAPES ARE CONTAMINATED WITH BODY FLUIDS.
Torbot Custom Compression
JOBSKIN COMPRESSION GARMENT For Burnscar Management and Scar Hypertrophy
Email [email protected] or fax completed order forms to 800-207-1579
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PO #
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HOTLINE
TORBOT GROUP PATIENT NUMBER (reorders only)
PATIENT
DOB (mm/yyyy)SEX
LAST NAME FIRST NAME
ZIP CODE
ADDRESS CITY STATE
COUNTRY- PHONE
Original Exact Reorder Reorder with Changes
DATE:
ZIP CODE
LAST NAME FIRST NAME
ADDRESS CITY STATE
- COUNTRY
PRESCRIBER
ID#
COMPRESSION: Burn Standard (15-30 mmHg) Other:_________ (burn standard used if blank)
Order Type
DIAGNOSIS: Burn Survivor Scar Management
Guaranteed to ship in 3 business days (additional cost)
4 MEASURED BYNAME FACILITY
EMAILPHONE FAX
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ZIP CODE
ADDRESS CITY STATE
COUNTRY- PHONE
FAX
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ZIP CODE
ADDRESS CITY STATE
COUNTRY PHONE
BILL TO ATTN FAX
ATTN
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7 LOWER EXTREMITIES LEG CIRCUMFERENCES
If spine of measuring device was pleated, give center-to-center distance between those tapes in eighths. All measurements in 1/8in units. Enter inches and 1/8ths for all. EXAMPLE: = 12 6/8" = 7 3/8"
71/2
6
41/2
3
11/2
Heel 0
11/2
3
41/2
6
71/2
9
101/2
12
131/2
15
161/2
18
191/2
21
221/2
24
251/2
27
281/2
30
311/2
33
341/2
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PLEATS PLEATSLEFT RIGHTTAPE#
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Pleat at end of
foot only (max 2)
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Pleat at top
only (max 1)
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8 STYLES CAT# Qty Left
Qty Right
Qty Other
PRICE EACH TOTAL
Anklet 0105
Knee Length 0101
Thigh Length 0201
Waist Height, Two Legs, Closed Pubis 1101
Waist Height, Two Legs, Open Pubis 1102
Waist Height, One Leg, Open Pubis 1103
Waist Height, One Leg Panty, Closed Pubis 1113
Panty Girdle, Two legs, Above Knee, Closed Pubis 1119
Panty Girdle, Two Legs, Below Knee, Closed Pubis 1111
Panty Girdle, Two Legs, Below Knee, Open Pubis 1110
9 OPTIONS CAT# Qty Left
Qty Right
Qty Other
PRICE EACH TOTAL
Reinforced Heel (per leg) 1187
Reinforced Knee (per leg) 1186
Lining Behind Knee (per leg) 0040
Self-material Enclosed Toes (mark foot lengths at comments) 1159
Soft Material Enclosed Toes 1160
Zipper (each opening). Mark location below in zipper options 1164
Velcro Tabs for Vest Attachment (set of 4) 1163
Oversize Charge (If largest circumference measurement is 50 - 59" (127 - 151 cm)
1177
If largest circumference measurement is 60-69"(152 - 177 cm) 0031
If Largest circumference measurement is 70-79" (178-201 cm) 0042
Contracture Seam 0176
1" Silicone Band 1118
2" Silicone Band 0160Attached Suspenders (Children under 3 n/c) 0090
Attached Suspenders 1162
10 SUBTOTAL
ZIPPER OPTIONS Full length zipper is standard for burns (Vascular=10inches). If shorter zipper is desired, provide length in whole inches.
LOCATION (X) LENGTH (inches)
LEFT RIGHT LEFT RIGHT
LATERAL (outside) ASPECT (std.)
MEDIAL (inside) ASPECT
IN BODY ONLY (begins at top)SEE PRICE LIST FOR CATALOG NUMBER(S) OF ADDITIONAL STYLES AND OPTIONS. WAIST HEIGHT GARMENTS REQUIRE MEASUREMENTS 1-9 ON PAGE 3. Page 2 of 7
Comments
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11 TORSO Note: A prefix of 5911 will be added to all Burn catalog #'s and 5917 will be added to all Vascular catalog #'s.
STYLES CAT# Qty PRICE EACH TOTAL REQUIRED
MEASUREMENTS
Vest, sleeveless* 0525 1; 10-14;17
Vest, 1 long sleeve and 1 short sleeve* 0524 1; 10-14; 17; arm(s)
Vest, 2 short sleeves* 0526 1; 10-14; 17; arm(s)
Vest, 2 long sleeves* 0527 1; 10-14; 17; arm(s)
Body Brief, sleeveless 0530 1; 5; 7; 9-17
Body Brief, with sleeves 0531 1; 5; 7; 9-17; arm(s)
Bodysuit, sleeveless with legs 0558 1; 5; 7; 9-17; leg(s)
Bodysuit, with sleeves and legs 0560 1; 5; 7; 9-17; arm(s);
leg(s);
12 Subtotal
14 OPTIONS CAT# Qty PRICE EACH TOTAL
Reduced Pressure Abdominal Panel 1161
Velcro Tabs for Vest Attachment (set of 4) 1163Reinforced Inner Thigh & Perineum (Bodysuit only) 1185Oversize Charge If largest circumference is 50-59" (127-151 cm) 1177Oversize Charge If largest circumference is 60-69" (152-177 cm) 0031
Oversize Charge If largest circumference is 70-79" (178-201 cm) 0042
1" Silicone Band 1118
2" Silicone Band 0160
15 Subtotal
16 DESIGN CHOICES
Front Closure Zipper
Front Closure Velcro
Back Closure Zipper
Back Closure Velcro
Open Axilla LT RT
Meshed Axilla LT RT
Self Axilla LT RT
Turtleneck
Scoop Neck
V Neck
If arm or leg measurements are required, go to 7 (leg), or 17 (arm). If options are required, go to 9 (leg), or 19 (arm).
Comments
13 TORSO/BODY MEASUREMENTS CIRCUMFERENCE HEIGHT
Desired Top of Support
Waist 1 2
Midpoint between 1 and 5 3 4
Largest Part of Buttocks 5 6
Proximal Thigh Left (at fold of buttocks) 7 8
Proximal Thigh Right (at fold of buttocks) 9 8
Left Shoulder 10
Right Shoulder 11
Neck 12
Shoulder Width 13
Shoulder to Waist 14
Shoulder to Largest Part of Buttocks 15
Shoulder to Fold of Buttocks 16
Chest 17
ADDITIONAL MEASUREMENTS FOR BRA CUPS
Shoulder to Just Under Breast A
Circumference Just Under Breast B
Circumference Over Nipple Line C
* VEST BELOW WAIST
Shoulder to End of Support
Circumference at End of Support
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20 ZIPPER LENGTH Full length zipper is standard. If shorter zipper is desired, please indicate length from wrist in whole inches.
ARM CIRCUMFERENCES If spine of measuring tape was pleated, give center-to-center distance between tapes only at axilla, wrist, and gauntlet. All measurements in 1/8in units. Enter inches and 1/8ths for all. Enter elbow measurements beside box marked "Elbow" (Tape#9). EXAMPLE: = 12 6/8" = 7 3/8"
17 ARM
4 1/2
3
1 1/2
0
1 1/2
3
4 1/2
6
7 1/2
Elbow 9
10 1/2
12
13 1/2
15
16 1/2
18
19 1/2
PLEATS PLEATSLEFT RIGHTTAPE#
18 STYLES CAT# Qty Left
Qty Right
PRICE EACH TOTAL
Forearm Sleeve (wrist to elbow) 0515
Forearm Sleeve with Gauntlet (metacarpals to elbow) 0516
Arm Sleeve (wrist to axilla) 0501
Arm Sleeve with Attached Shoulder Flap 0503
Arm Sleeve with Attached Gauntlet (metacarpals to axilla) 0502
Detachable Gauntlet 0505
19 OPTIONS CAT# Qty Left
Qty Right
PRICE EACH TOTAL
Zipper (each opening) Mark Length at (20) 1164
Lining Inside Elbow 1167
Lining Full Elbow 1168
Adjustable ShoulderFlap (see 22) 1172
Contracture Seam 0176
1" Silicone Band 1118
2" Silicone Band 0160
23 Subtotal
LOCATION (x) LENGTH (in inches)
LEFT RIGHT LEFT RIGHT
Standard zipper - Lateral (radial) (outside)Aspect
Medial (ulnar) (inside) Aspect
Posterior (back of hand)
Anterior (palm of hand)
21 GAUNTLET
Circumference of Thumb
Left Right
Desired Thumb Length
Left Right
Thumb Open Tip
Yes No
22 SHOULDER FLAP
SHOULDER FLAP length diagonally from top
of shoulder to waist or below breast
Left Right
Provide circumference at waist or below breast if adjustable flap is requested
COMMENTS
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25 GLOVE OPTIONS CAT# Qty Left
Qty Right
PRICE EACH TOTAL
Slant Inserts 1169
1" Silicone Band 1118
2" Silicone Band 0160
Zipper (each opening) Mark location below 1164
Zipper Location (Mark [X]) Ulnar (little finger)(STANDARD))
Zipper Location (Mark [X]) Dorsal (Posterior)
Zipper Location (Mark [X]) Palmar (Anterior)
open tip(s)
[X]Left *Lengths Right
open tip(s)
[X]
12-Little finger to web between little and ring fingers.
13-Ring finger to web between ring and middle fingers.
14-Middle finger to web between middle and index fingers.
15-Index finger to web between middle and index fingers.
16-Thumb to thumb web.
17-Wrist to web between little and ring fingers.
18-Wrist to web between middle and ring fingers.
19-Wrist to web between index and middle fingers.
20-Wrist to thumb web.
24 GLOVE STYLES CAT# Qty Left
Qty Right
PRICE EACH TOTAL
Glove to Wrist 0535
Glove to Elbow 0534
Interdigital Web Spacer (worn over glove) 0536
27 CIRCUMFERENCE
Left Circumference Right
1-Little Finger DIP
2-Little Finger PIP
3-Ring Finger DIP
4-Ring Finger PIP
5-Middle Finger DIP
6-Middle Finger PIP
7-Index Finger DIP
8-Index Finger PIP
9-Thumb IP
10-Palm
11-Wrist
1 1/2" Beyond Wrist
3" Beyond Wrist
IMPORTANT - COMPLETED HAND OUTLINE WITH SCALE IS REQUIRED * Open Tip Glove length measurement is finished length desired.
26 Subtotal
28 HEAD STYLES CAT# Qty PRICE EACH TOTAL
Face Mask 0540
Face Mask, Open Face 1158
Chin Strap 0550
Chin Strap, Modified (extends behind ear) 0549
29 HEAD OPTIONS CAT# Qty PRICE EACH TOTAL
Lip Covering 1166
Nose Covering 1165
30 Subtotal
31 HEAD MEASUREMENTS
Masks/Chin Straps Measurement
1-Width of Eyes
2-Length of Ear
3-Width of Mouth
4-Chin to Eyes
5-Chin to Mouth
6-Circ. above Eyebrow
7-Around Head at Chin Angle
8-Circ. of Neck
Measurement (use only if ordering a nose cover)
A-Across Tip of Nose
B-Length of Nose
COMMENTS
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CUSTOM ORDER SKETCH PAD
Patient Name
Torbot Patient #
Date
Fig. 1 Fig. 2
Fig. 3 Fig. 4
Use this sketch pad to draw , or mark the locations of special linings and any other feature that cannot be indicated on the order form. Please use a dark pen or pencil and clearly mark the area as legibly as possible. Be sure to provide measurements indicating exact size and locations of requested items. IMPORTANT INDICATIONS FOR SILON 1) Do NOT request silon be added to more than 50% of your garment. Compression cannot be guaranteed or reliable when a garment contains that volume of silon. 2) We recommend zippers for garments containing silon to make the garment easier to put on and take off. If possible, print this page and sketch your locations. Then fax the form to us. If ordering electronically, please describe locations in detail.
Torbot Fax
Torbot Customer Service
Comments
ACCUMULATED SUBTOTALS
Subtract 10% of Subtotals for Children Under Age 6
Add Hot-Line Service Fee - 30% of Subtotals (if applicable)
Shipping Fee
International Shipping Fee
Minimum Handling Fee (if applicable) (see price list)
TOTAL
NOTICE: WE DO NOT ACCEPT THIRD PARTY BILLINGS
FOR TORBOT GROUP, INC., USE ONLY
SALES ORDER
PATIENT
PRESCRIBER
SHIP TO
BILL TO
P.O.
ID
PACKED BY
QUANTITY
Warranty in general Torbot Group-Jobskin Division will replace any problem compression garment for fit and workmanship, free of charge, within 30 calendar days (Warranty Period) of being shipped from our manufacturing facility. As soon as a problem is identified to The Torbot Group, another garment will be manufactured at our discretion. If this is the case a replacement will be manufactured immediately. We will not wait until the problem garment is returned (unless the problem cannot be determined without seeing the garment). Any problem garment shall be returned to Torbot Group as soon as possible. Please provide as much information as possible so that we can conduct a full investigation. Without the return of the garment, it is difficult to determine the exact nature of the problem and find a remedy. All returned garments must be clean/laundered to minimize any potential risk of infection. Torbot Group is unable to accept any garment that is not clean when returned and such garments may be destroyed immediately. If the replacement garment requires significantly different measurements, the replacement garment will generally be treated as a reorder.
Remittance to: Torbot Group, Inc., Jobskin Div. 5030 Advantage Dr. , Suite 101 Toledo, Oh 43612
Signature ________________________________________
Credit Card
Exp. Date /
Security Code
PLEASE CHARGE TO MY
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Jobskin Customer Service: Torbot Group Inc., Jobskin Division 5030 Advantage Drive, Suite 101 Toledo, Ohio 43612 Fax: 800.207.1579 or 419.724.1476/1477 Phone: 800.207.1074 or 419.724.1478
Torbot Group Inc. - World Class Compression Garments World Class Ostomy Products Thank You for Your Purchase!
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