Allergan Plastic Surgery Product Order Form
[Pages:3]Patient identifier Surgery date
Doctor Surgery location
Office contact Notes
Allergan Aesthetics Plastic Surgery Product Order Form
KELLER FUNNEL?2
DESCRIPTION Case of 5
CATALOG NUMBER
QTY
HA-005
REVOLVETM Advanced Adipose System
DESCRIPTION Case of 1
CATALOG NUMBER
QTY
RV0001
SMOOTH ROUND GEL BREAST IMPLANTS & SIZERS
Styles SCX, SSX, & SRX
VOLUME (cc) 200 225 255 285 310 340 375 400 420 445 470 495 525 545 560 580 615 650 700 750 800
DIAMETER (cm) 9.50 10.00 10.25 10.50 10.75 11.00 11.25 11.50 11.75 12.00 12.25 12.50 12.75 13.00 13.25 13.50 13.75 14.00 14.25 14.50 15.50
PROJECTION (cm) 4.2 4.5 4.8 5.0 5.2 5.4 5.6 5.8 5.9 6.0 6.1 6.1 6.2 6.2 6.3 6.4 6.4 6.5 6.6 6.7 6.7
Styles SCF, SSF, & SRF
VOLUME (cc) 180 200 220 240 265 295 325 335 345 365 385 415 450 485 520 560 605 650 695 745 770
DIAMETER (cm) 9.50 9.75 10.00 10.50 11.00 11.25 11.40 11.50 11.75 12.00 12.25 12.50 12.75 13.00 13.25 13.50 14.00 14.50 14.75 15.00 15.50
PROJECTION (cm) 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 5.0 5.1 5.3 5.4 5.5 5.7 5.8 5.9 6.0 6.1 6.0
SMOOTH COHESIVE (SCX)
QTY
SCX-200
SCX-225
SCX-255
SCX-285
SCX-310
SCX-340
SCX-375
SCX-400
SCX-420
SCX-445
SCX-470
SCX-495
SCX-525
SCX-545
SCX-560
SCX-580
SCX-615
SCX-650
SCX-700
SCX-750
SCX-800
SMOOTH COHESIVE (SCF)
QTY
SCF-180
SCF-200
SCF-220
SCF-240
SCF-265
SCF-295
SCF-325
SCF-335
SCF-345
SCF-365
SCF-385
SCF-415
SCF-450
SCF-485
SCF-520
SCF-560
SCF-605
SCF-650
SCF-695
SCF-745
SCF-770
SMOOTH SOFTTOUCH (SSX)
QTY
SSX-200
SSX-225
SSX-255
SSX-285
SSX-310
SSX-340
SSX-375
SSX-400
SSX-420
SSX-445
SSX-470
SSX-495
SSX-525
SSX-545
SSX-560
SSX-580
SSX-615
SSX-650
SSX-700
SSX-750
SSX-800
SMOOTH SOFTTOUCH (SSF)
QTY
SSF-180
SSF-200
SSF-220
SSF-240
SSF-265
SSF-295
SSF-325
SSF-335
SSF-345
SSF-365
SSF-385
SSF-415
SSF-450
SSF-485
SSF-520
SSF-560
SSF-605
SSF-650
SSF-695
SSF-745
SSF-770
EXTRA-FULL PROFILE
SMOOTH RESPONSIVE (SRX)
QTY
SRX-200
SRX-225
SRX-255
SRX-285
SRX-310
SRX-340
SRX-375
SRX-400
SRX-420
SRX-445
SRX-470
SRX-495
SRX-525
SRX-545
SRX-560
SRX-580
SRX-615
SRX-650
SRX-700
SRX-750
SRX-800
SMOOTH RESPONSIVE (SRF)
SRF-180 SRF-200 SRF-220 SRF-240 SRF-265 SRF-295 SRF-325 SRF-335 SRF-345 SRF-365 SRF-385 SRF-415 SRF-450 SRF-485 SRF-520 SRF-560 SRF-605 SRF-650 SRF-695 SRF-745 SRF-770
FULL PROFILE
QTY
RE-STERILIZABLE GEL SIZER
CATALOG NUMBER
QTY
MSZ-X205 MSZ-X225 MSZ-X255 MSZ-X285 MSZ-X310 MSZ-X340 MSZ-X375 MSZ-X400 MSZ-X420 MSZ-X445 MSZ-X470 MSZ-X495 MSZ-X525 MSZ-X545 MSZ-X560 MSZ-X580 MSZ-X615 MSZ-X650 MSZ-X700 MSZ-X750 MSZ-X800
RE-STERILIZABLE GEL SIZER
CATALOG NUMBER
QTY
MSZ-F180 MSZ-F200 MSZ-F220 MSZ-F240 MSZ-F265 MSZ-F295 MSZ-F325 MSZ-F335 MSZ-F345 MSZ-F365 MSZ-F385 MSZ-F415 MSZ-F450 MSZ-F485 MSZ-F520 MSZ-F560 MSZ-F605 MSZ-F650 MSZ-F695 MSZ-F745 MSZ-F770
SINGLE-USE GEL SIZER
CATALOG NUMBER
QTY
SSZ-X205 SSZ-X225 SSZ-X255 SSZ-X285 SSZ-X310 SSZ-X340 SSZ-X375 SSZ-X400 SSZ-X420 SSZ-X445 SSZ-X470 SSZ-X495 SSZ-X525 SSZ-X545 SSZ-X560 SSZ-X580 SSZ-X615 SSZ-X650 SSZ-X700 SSZ-X750 SSZ-X800
SINGLE-USE GEL SIZER
CATALOG NUMBER
QTY
SSZ-F180 SSZ-F200 SSZ-F220 SSZ-F240 SSZ-F265 SSZ-F295 SSZ-F325 SSZ-F335 SSZ-F345 SSZ-F365 SSZ-F385 SSZ-F415 SSZ-F450 SSZ-F485 SSZ-F520 SSZ-F560 SSZ-F605 SSZ-F650 SSZ-F695 SSZ-F745 SSZ-F770
To order Allergan Aesthetics Plastic Surgery products, please call Customer Service at 1-800-766-0171.
? 2022 AbbVie. All rights reserved. All trademarks are the property of their respective owners. hcp MBD92309-v6 01/22 015054
Patient identifier Surgery date
Doctor Surgery location
Office contact Notes
Allergan Aesthetics Plastic Surgery Product Order Form
SMOOTH ROUND GEL BREAST IMPLANTS & SIZERS (continued)
Styles SCM, SSM, & SRM
VOLUME (cc) 140 175 195 210 240 255 275 295 310 330 345 360 375 405 445 485 520 560 600 640 685 755
DIAMETER (cm) 9.50 10.00 10.25 10.50 11.00 11.25 11.50 11.75 12.00 12.25 12.50 12.75 13.00 13.25 13.50 14.00 14.50 14.75 15.00 15.50 16.00 16.50
PROJECTION (cm) 3.0 3.3 3.4 3.5 3.7 3.8 3.9 3.9 4.0 4.1 4.2 4.2 4.3 4.4 4.5 4.6 4.8 4.9 4.9 5.0 5.2 5.0
Styles SCLP, SSLP, & SRLP
VOLUME (cc) 125 145 165 190 205 220 235 250 265 280 300 320 340 360 400 440 490 540 590 640
DIAMETER (cm) 9.50 10.00 10.50 11.00 11.25 11.50 11.75 12.00 12.25 12.50 12.75 13.00 13.25 13.50 14.00 14.50 15.00 15.50 16.00 16.50
PROJECTION (cm) 2.5 2.6 2.7 2.8 2.9 3.0 3.1 3.1 3.2 3.3 3.3 3.4 3.5 3.5 3.6 3.8 3.9 4.0 4.2 4.3
Styles SCL, SSL, & SRL
VOLUME (cc) 110 125 140 170 200 230 260 290 320 350 380 410 460 510 560 610
DIAMETER (cm) 10.00 10.25 10.50 11.00 11.50 12.00 12.50 13.00 13.50 14.00 14.50 15.00 15.50 16.00 16.50 17.00
PROJECTION (cm) 2.0 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 3.0 3.1 3.2 3.3 3.4
SMOOTH COHESIVE (SCM)
QTY
SCM-140
SCM-175
SCM-195
SCM-210
SCM-240
SCM-255
SCM-275
SCM-295
SCM-310
SCM-330
SCM-345
SCM-360
SCM-375
SCM-405
SCM-445
SCM-485
SCM-520
SCM-560
SCM-600
SCM-640
SCM-685
SCM-755
SMOOTH COHESIVE (SCLP)
QTY
SCLP-125
SCLP-145
SCLP-165
SCLP-190
SCLP-205
SCLP-220
SCLP-235
SCLP-250
SCLP-265
SCLP-280
SCLP-300
SCLP-320
SCLP-340
SCLP-360
SCLP-400
SCLP-440
SCLP-490
SCLP-540
SCLP-590
SCLP-640
SMOOTH COHESIVE (SCL)
QTY
SCL-110
SCL-125
SCL-140
SCL-170
SCL-200
SCL-230
SCL-260
SCL-290
SCL-320
SCL-350
SCL-380
SCL-410
SCL-460
SCL-510
SCL-560
SCL-610
SMOOTH SOFTTOUCH (SSM)
QTY
SSM-140
SSM-175
SSM-195
SSM-210
SSM-240
SSM-255
SSM-275
SSM-295
SSM-310
SSM-330
SSM-345
SSM-360
SSM-375
SSM-405
SSM-445
SSM-485
SSM-520
SSM-560
SSM-600
SSM-640
SSM-685
SSM-755
SMOOTH SOFTTOUCH (SSLP)
QTY
SSLP-125
SSLP-145
SSLP-165
SSLP-190
SSLP-205
SSLP-220
SSLP-235
SSLP-250
SSLP-265
SSLP-280
SSLP-300
SSLP-320
SSLP-340
SSLP-360
SSLP-400
SSLP-440
SSLP-490
SSLP-540
SSLP-590
SSLP-640
SMOOTH SOFTTOUCH (SSL)
QTY
SSL-110
SSL-125
SSL-140
SSL-170
SSL-200
SSL-230
SSL-260
SSL-290
SSL-320
SSL-350
SSL-380
SSL-410
SSL-460
SSL-510
SSL-560
SSL-610
SMOOTH RESPONSIVE (SRM)
SRM-140 SRM-175 SRM-195 SRM-210 SRM-240 SRM-255 SRM-275 SRM-295 SRM-310 SRM-330 SRM-345 SRM-360 SRM-375 SRM-405 SRM-445 SRM-485 SRM-520 SRM-560 SRM-600 SRM-640 SRM-685 SRM-755
MODERATE PROFILE
QTY
SMOOTH RESPONSIVE (SRLP)
SRLP-125 SRLP-145 SRLP-165 SRLP-190 SRLP-205 SRLP-220 SRLP-235 SRLP-250 SRLP-265 SRLP-280 SRLP-300 SRLP-320 SRLP-340 SRLP-360 SRLP-400 SRLP-440 SRLP-490 SRLP-540 SRLP-590 SRLP-640
LOW-PLUS PROFILE
QTY
SMOOTH RESPONSIVE (SRL)
SRL-110 SRL-125 SRL-140 SRL-170 SRL-200 SRL-230 SRL-260 SRL-290 SRL-320 SRL-350 SRL-380 SRL-410 SRL-460 SRL-510 SRL-560 SRL-610
LOW PROFILE
QTY
RE-STERILIZABLE GEL SIZER
CATALOG NUMBER
QTY
MSZ-M140 MSZ-M175 MSZ-M195 MSZ-M210 MSZ-M240 MSZ-M255 MSZ-M275 MSZ-M295 MSZ-M310 MSZ-M330 MSZ-M345 MSZ-M360 MSZ-M375 MSZ-M405 MSZ-M445 MSZ-M485 MSZ-M520 MSZ-M560 MSZ-M600 MSZ-M640 MSZ-M685 MSZ-M755
RE-STERILIZABLE GEL SIZER
CATALOG NUMBER
QTY
MSZ-LP125 MSZ-LP145 MSZ-LP165 MSZ-LP190 MSZ-LP205 MSZ-LP220 MSZ-LP235 MSZ-LP250 MSZ-LP265 MSZ-LP280 MSZ-LP300 MSZ-LP320 MSZ-LP340 MSZ-LP360 MSZ-LP400 MSZ-LP440 MSZ-LP490 MSZ-LP540 MSZ-LP590 MSZ-LP640
RE-STERILIZABLE GEL SIZER
CATALOG NUMBER
QTY
MSZ-L110 MSZ-L125 MSZ-L140 MSZ-L170 MSZ-L200 MSZ-L230 MSZ-L260 MSZ-L290 MSZ-L320 MSZ-L350 MSZ-L380 MSZ-L410 MSZ-L460 MSZ-L510 MSZ-L560 MSZ-L610
To order Allergan Aesthetics Plastic Surgery products, please call Customer Service at 1-800-766-0171.
SINGLE-USE GEL SIZER
CATALOG NUMBER
QTY
SSZ-M140 SSZ-M175 SSZ-M195 SSZ-M210 SSZ-M240 SSZ-M255 SSZ-M275 SSZ-M295 SSZ-M310 SSZ-M330 SSZ-M345 SSZ-M360 SSZ-M375 SSZ-M405 SSZ-M445 SSZ-M485 SSZ-M520 SSZ-M560 SSZ-M600 SSZ-M640 SSZ-M685 SSZ-M755
SINGLE-USE GEL SIZER
CATALOG NUMBER
QTY
SSZ-LP125 SSZ-LP145 SSZ-LP165 SSZ-LP190 SSZ-LP205 SSZ-LP220 SSZ-LP235 SSZ-LP250 SSZ-LP265 SSZ-LP280 SSZ-LP300 SSZ-LP320 SSZ-LP340 SSZ-LP360 SSZ-LP400 SSZ-LP440 SSZ-LP490 SSZ-LP540 SSZ-LP590 SSZ-LP640
SINGLE-USE GEL SIZER
CATALOG NUMBER
QTY
SSZ-L110 SSZ-L125 SSZ-L140 SSZ-L170 SSZ-L200 SSZ-L230 SSZ-L260 SSZ-L290 SSZ-L320 SSZ-L350 SSZ-L380 SSZ-L410 SSZ-L460 SSZ-L510 SSZ-L560 SSZ-L610
? 2022 AbbVie. All rights reserved. All trademarks are the property of their respective owners. MBD92309-v6 01/22 015054
Patient identifier Surgery date
Doctor Surgery location
Office contact Notes
Allergan Aesthetics Plastic Surgery Product Order Form
SMOOTH ROUND SALINE-FILLED BREAST IMPLANTS & SIZERS
Style 68HP
ANTERIOR DIAPHRAGM VALVE
DIMENSIONS AT MINIMUM VOLUME
FILL VOLUME (cc)
160-175 200-220 240-260 280-300 320-340 350-380 400-430 425-455 465-505 500-540 550-590 600-640 650-700 700-750 750-800 800-850
DIAMETER (cm)
9.0 9.6 10.2 10.6 11.1 11.6 11.9 12.3 12.6 13.0 13.3 13.7 14.0 14.4 14.6 15.0
PROJECTION (cm)
3.9 4.2 4.4 4.7 4.9 4.9 5.0 5.3 5.6 5.7 5.8 6.0 6.1 6.2 6.5 6.7
HIGH PROFILE
DIMENSIONS AT MAXIMUM VOLUME
DIAMETER (cm)
8.8 9.5 10.0 10.5 11.0 11.4 11.7 12.1 12.5 12.8 13.1 13.5 13.8 14.1 14.4 14.7
PROJECTION (cm)
4.3 4.6 5.0 5.2 5.3 5.5 5.9 5.9 6.1 6.3 6.4 6.6 6.9 7.1 7.2 7.2
CATALOG NUMBER QTY
68HP-160 68HP-200 68HP-240 68HP-280 68HP-320 68HP-350 68HP-400 68HP-425 68HP-465 68HP-500 68HP-550 68HP-600 68HP-650 68HP-700 68HP-750 68HP-800
SINGLE-USE SALINE SIZER
CATALOG NUMBER
QTY
??? SZHP68200
??? SZHP68280 SZHP68320 SZHP68350 SZHP68400 SZHP68425 SZHP68465 SZHP68500 SZHP68550
??? SZHP68650
??? SZHP68750
???
Style 68LP
ANTERIOR DIAPHRAGM VALVE
FILL VOLUME (cc)
125-145 150-170 175-195 200-220 225-245 250-270 275-295 300-320 325-345 350-370 400-420 420-440 440-460 480-500 525-545 550-570 600-620 640-660 680-700
DIMENSIONS AT MINIMUM VOLUME
DIAMETER (cm)
9.5 10.0 10.6 11.0 11.4 11.9 12.2 12.5 12.9 13.3 13.5 13.9 14.2 14.5 14.8 15.1 15.4 15.8 16.2
PROJECTION (cm)
2.6 2.7 2.8 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.8 3.9 3.9 4.0 4.2 4.3 4.4 4.5 4.5
LOW PROFILE
DIMENSIONS AT MAXIMUM VOLUME
DIAMETER (cm)
9.3 9.9 10.4 10.9 11.3 11.7 12.1 12.4 12.7 13.2 13.4 13.8 14.1 14.4 14.7 15.0 15.3 15.7 16.1
PROJECTION (cm)
3.2 3.2 3.3 3.4 3.4 3.5 3.6 3.7 3.8 3.8 4.2 4.1 4.1 4.3 4.5 4.5 4.6 4.7 4.7
CATALOG NUMBER
QTY
68LP-125
68LP-150
68LP-175
68LP-200
68LP-225
68LP-250
68LP-275
68LP-300
68LP-325
68LP-350
68LP-400
68LP-420
68LP-440
68LP-480
68LP-525
68LP-550
68LP-600
68LP-640
68LP-680
SINGLE-USE SALINE SIZER
CATALOG NUMBER
QTY
??? SZLP68150 SZLP68175 SZLP68200 SZLP68225
??? SZLP68275 SZLP68300 SZLP68325 SZLP68350 SZLP68400 SZLP68420
??? SZLP68480 SZLP68525 SZLP68550 SZLP68600 SZLP68640
???
Style 68MP
ANTERIOR DIAPHRAGM VALVE
DIMENSIONS AT MINIMUM VOLUME
FILL VOLUME (cc)
120-150 150-180 180-210 210-240 240-270 270-300 300-330 330-360 360-390 390-420 420-450 450-480 480-510 510-540 550-600 600-650 650-700 700-750 750-800 800-850
DIAMETER (cm)
9.0 9.6 10.2 10.6 11.1 11.6 11.9 12.3 12.7 13.0 13.4 13.7 14.1 14.4 14.6 15.0 15.2 15.6 15.9 16.4
PROJECTION (cm)
3.0 3.3 3.4 3.7 3.8 3.9 4.1 4.2 4.2 4.5 4.5 4.6 4.6 4.6 4.9 5.0 5.3 5.4 5.6 5.6
DIMENSIONS AT MAXIMUM VOLUME
DIAMETER (cm)
8.9 9.5 10.1 10.5 11.0 11.5 11.8 12.2 12.6 12.9 13.3 13.6 14.0 14.3 14.5 14.9 15.1 15.5 15.8 16.3
PROJECTION (cm)
3.5 3.8 3.9 4.1 4.2 4.3 4.4 4.5 4.5 4.6 4.6 4.7 4.7 4.7 5.1 5.2 5.5 5.6 5.8 5.8
MODERATE PROFILE
CATALOG NUMBER QTY
68-120 68-150 68-180 68-210 68-240 68-270 68-300 68-330 68-360 68-390 68-420 68-450 68-480 68-510 68-550 68-600 68-650 68-700 68-750 68-800
SINGLE-USE SALINE SIZER
CATALOG NUMBER
QTY
??? ??? SZ68180 SZ68210 SZ68240 SZ68270 SZ68300 SZ68330 SZ68360 SZ68390 SZ68420 SZ68450 SZ68480 SZ68510 ??? ??? SZ68650 ??? ??? ???
To order Allergan Aesthetics Plastic Surgery products, please call Customer Service at 1-800-766-0171.
? 2022 AbbVie. All rights reserved. All trademarks are the property of their respective owners. MBD92309-v6 01/22 015054
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