Compression Garment Referral Form - Gottfried Medical

Compression Garment Referral Form

Form F-027

101 Wrist to axilla

102 Gauntlet to axilla

103 Wrist through flap

104 Gauntlet through flap

106 Gauntlet

403 Wrist to elbow

404 Gauntlet to elbow

405 Sleeve stump

406 Sleeve stump w/flap

409 Elbow to axilla

400 Glove to axilla

401 Glove to wrist

402 Glove to elbow

407 Glove through shoulder flap

451 Mitten to wrist

452 Mitten to elbow

201 Knee length

202 Thigh length

331 Stump above knee

332 Stump below knee

300 Chap style

one leg

301 One leg open crotch

302 One leg panty open crotch

303 One leg panty closed crotch

304

305

306

Waist high 2 leg Waist high 2 leg Waist high 2

open crotch closed crotch leg pregnancy

307 Chap style

two legs

308 Panty girdle above knee

309 Panty girdle below knee

333

334

335

336

One stump One stump panty One stump panty Leg & stump

open crotch open crotch closed crotch open crotch

410 Vest sleeveless

412 Vest with sleeves

413

414

415

416

417

418

420

421

422

430

Sternum

Vest brief

Vest brief

Vest brief

Vest brief

Suit w/legs Suit w/sleeves Suit w/sleeves Suit w/sleeves

Mask

pressure support sleeveless

sleeveless

w/sleeves

w/sleeves

above knee

& legs

one leg

two legs

w/velcro flap open crotch w/velcro flap open crotch

above knee bleow knee below knee

431 Mask open face

432 Chin strap

441 MR Bolero one arm

Form F-027 Rev. B Document Level 4

441 ML Bolero one arm female

442 M Bolero two arm

442 F Bolero two arm female

408 Anklet

453 Finger sleeve

460 Foot glove to ankle

461 Foot glove

to knee

470 Knee band

471 Thigh band above knee

472 Arm band

One & two Leg

Garter Belts

? Gottfried Medical, Inc. Rev. 2019 12-23

PLEASE DIRECT ALL ORDERS TO:

office:

+1 419 474-2973 Patient Name:

2920 Centennial Rd., Toledo OH 43617-1833 toll-free: +1 800 537-1968

? sales@ toll-free fax: +1 866 474-8822 Ordering Facility:

NOTICE TO PATIENT

Please take this form to an authorized Gottfried Medical Dealer

for ordering, measuring and fitting. Please contact us at the number above if you require

assistance in locating a dealer.

NOTES

Compression (mmHg): 22-28 (Burns) | 20-30 | 30-40 | 40-50 | 50-60

REQUIRED Allergies: Allergic to silicone? Yes, No, NA | Allergic to metal? Yes, No, NA

OPTIONS

Toe Caps: *Foot tracing required for Closed Toe

Open Toe Soft Toe*

Foot Length: (Please include foot tracing)

Self Toe*

Left ________

Right ________

Zipper: Open (Allows garment to be completely open) Closed (Does not open completely, allows for easier donning)

Flex Seams: Ankle Back of Knee Elbow Other ________________

Elastic Bands: Regular - 1" Regular - 2"

Silicone - 1" Silicone - 2"

Mircodot - 2"

Garment Lining: Medial Side AKA: REINFORCEMENT Lateral Side

Heel Ankle

ORDERING FACILITY INFORMATION

Facility Name:

Contact Name:

Phone:

Fax:

Email:

Form F-027 Rev. B Document Level 4

FORM

Date:

F-027

? Gottfried Medical, Inc. Rev. 2019 12-23

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