Compression Order
Location
Andrews AFB
Chantilly
Ft. Belvoir
Ft. Bliss
Ft. Bragg
Ft. Campbell
Ft. Carson
Ft. Hood
Ft. Lewis-McChord
Ft. Stewart
Hunter Army Airfield
Nellis AFB
Staff Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Patient's Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Ship to:
*
Store
Direct ship to patient's home
If shipping to the patient's home, please provide the address below:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Item 1
Manufacturer:
Jobst
Medi
L&R
Sigvaris
Style (ex. Comfort, Relief) :
Type (ex. Knee-high, sleeve):
Color:
Size (ex. small, XL, I-VI):
Compression
8-15mmHg
15-20mmHg
20-30mmHg
30-40mmHg
40-50mmHg
Other-see notes
Catalog Number:
How many pairs:
Special Notes:
Item 2
Manufacturer:
Jobst
Medi
L&R
Sigvaris
Style (ex. Comfort, Relief) :
Type (ex. Knee-high, sleeve):
Color:
Size (ex. small, XL, I-VI):
Compression
8-15mmHg
15-20mmHg
20-30mmHg
30-40mmHg
40-50mmHg
Other-see notes
Catalog Number:
How many pairs:
Special Notes:
Item 3
Manufacturer
Jobst
Medi
L&R
Sigvaris
Style (ex. Comfort, Relief) :
Type (ex. Knee-high, sleeve):
Color:
Size (ex. small, XL, I-VI):
Compression
8-15mmHg
15-20mmHg
20-30mmHg
30-40mmHg
40-50mmHg
Other-see notes
Catalog Number:
How many pairs:
Special Notes:
Comments, Notes, Special Instructions
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