Request form for JOBST® Prescription
Upper Limb Compression Wrap System
JOBST® FARROWWRAP® LITE
READY-TO-WEAR ARMPIECE AND GAUNTLET
PLEASE ASK YOUR PATIENT TO PRESENT THIS FORM TO THEIR PRESCRIBER TO OBTAIN THE GARMENTS ON FP10 / GP10
Patient Name:
Date of Birth:
Date:
Contact Number:
Clinic:
Measured By:
Signature:
Length
Wrist
Elbow
Axilla
Small
14cm - 18cm
20cm - 27cm
22cm - 31cm
Short
40cm - 43cm
Medium
16cm - 21cm
25cm - 34cm
29cm - 39cm
Regular
44cm - 47cm
Large
19cm - 25cm
30cm - 40cm
32cm - 45cm
Long
48cm - 51cm
NOTE: Measure length from the outside of
the wrist to the axilla (G) with a slight bend
in arm
ARMPIECE
Size
Small MediumLarge
Compression
Circumference and length measurements in centimetres (cms)
LITE (20-30 mmHg)
Length
Short RegularLong
Side
LeftRight
Colour
Axilla
Left:
Right:
Left:
Right:
Left:
Right:
a:
b:
Left:
Right:
BeigeBlack
Elbow
GAUNTLET
Size
XSmall
Compression
Colour
Small
MediumLarge
LITE (20-30 mmHg)
Beige
Wrist
Measurement Points
XSmall
Small
Medium
Large
a - Palm at base of fingers
< 18cm
18-20cm
20-22cm
> 22cm
b - Palm at fold of thumb
< 19cm
19-21cm
21-23cm
> 24cm
Hand
a
b
a - Palm at base of fingers
b - Palm at fold of the thumb
If you have any queries, please call Customer Services on 0845 122 3600 or
email [email protected]
Customer Services Direct Fax: 0845 122 3450
JOBST® FARROWWRAP® LITE
READY-TO-WEAR ARMPIECE AND GAUNTLET ORDERING INFORMATION
Compression:20-30mmHg
Mild to moderate oedema / lymphoedema
A double-laminated fabric suitable for mild to moderate oedema levels, making it
especially suitable for palliative and paediatric patients. The fabric is both durable
and breathable.
Armpiece
Gauntlet
AVAILABLE ON FP10 / GP1O
BSN Code
Option
Size
Length
Colour
PIP
76650-11
76650-05
76650-35
76650-13
76650-07
76650-01
76650-15
76650-09
76650-03
76650-29
76650-23
76650-13
76650-31
76650-25
76650-19
76650-33
76650-27
76650-21
76650-12
76650-06
76650-00
76650-14
76650-08
76650-02
76650-16
76650-10
76650-04
76650-30
76650-24
76650-18
76650-32
76650-26
76650-20
76650-34
76650-28
76650-22
76653-00
76653-01
76653-02
76653-03
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Right
Ambidextrous
Ambidextrous
Ambidextrous
Ambidextrous
Small
Small
Small
Medium
Medium
Medium
Large
Large
Large
Small
Small
Small
Medium
Medium
Medium
Large
Large
Large
Small
Small
Small
Medium
Medium
Medium
Large
Large
Large
Small
Small
Small
Medium
Medium
Medium
Large
Large
Large
Extra small
Small
Medium
Large
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
Short
Regular
Long
-
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Black
Black
Black
Black
Black
Black
Black
Black
Black
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Black
Black
Black
Black
Black
Black
Black
Black
Black
Beige
Beige
Beige
Beige
392-6953
392-7019
392-7076
392-6961
392-7027
392-7084
392-6979
392-7035
392-7092
392-6987
392-7043
392-7100
392-6995
392-7050
392-7118
392-7001
392-7068
392-7126
392-6771
392-6839
392-6896
392-6789
392-6847
392-6904
392-6797
392-6854
392-6912
392-6805
392-6862
392-6920
392-6813
392-6870
392-6938
392-6821
392-6888
392-6946
404-5647
404-5654
404-5662
404-5670
Note: If your patient does not fit within the ready-to-wear (RTW) sizing chart for LITE or requires a STRONG or CLASSIC armpiece, then a custom-fit variant is
required. Custom-fit is not available on FP10 / GP10.
Further details available on request
ARMPIECE
GAUNTLET
PIP Code:
PIP Code:
BSN Code:
BSN Code:
(see overleaf for order codes)
(see overleaf for order codes)
Quantity Required:
Quantity Required:
1687/1016
Repeat prescription required every
months
BSN medical Limited. • PO Box 258 • Willerby • Hull • HU10 6WT
Tel: 01482 670100 • Fax: 01482 670111 • www.bsnmedical.co.uk
® Registered trade mark
© BSN medical Limited 2017
Repeat prescription required every
months