JOBST® FARROWWRAP®
Date:_______________ Purchase Order No.:______________________ Patient Name:_____________________________________ DoB______________
READY-TO-WEAR / CUSTOM-FIT ORDER FORM
AD - BELOW KNEE
Measured By:______________________________________________ Tel:_______________________ Email:__________________________________
Delivery Address:___________________________________________ Invoice Address:_____________________________________________________
FAX ORDER TO CUSTOMER SERVICES ON:
_______________________________________________________ ________________________________________________________________
0845 122 3450
Length measurements in
centimetres (cms)
Circumference measurements
in centimetres (cms)
XSmall
Small
Medium
large
Remarks
XLarge
Ready-to-wear pieces
A-D
NOTE:
Measure
posteriorly
and
follow leg
contour
Legpiece
Two finger widths D
below crease Left:
D
B
C
Widest calf
Left:
C
A-D
B
2
B
1
Right:
Left:
Narrowest ankle
Right:
B
Left:
36-43 cm
42-50 cm
48-58 cm
53-63 cm
58-68 cm
Ankle
21-25 cm
25-30 cm
30-36 cm
36-42 cm
42-50 cm
Regular
35-39 cm
37-41 cm
39-43 cm
41-45 cm
42-46 cm
Tall
40-44 cm
42-46 cm
44-48 cm
46-50 cm
47-51 cm
A1
Mid-foot
22-24 cm
25-27 cm
28-30 cm
31-34 cm
35-40 cm
X
Regular
15-17 cm
16-19 cm
18-20 cm
19-22 cm
21-24 cm
X
Tall
18-20 cm
20-22 cm
21-23 cm
23-25 cm
25-27 cm
Liners*
Right:
A1
Left:
A1
Calf
Footpiece
Right:
Left:
Midfoot
A-D
B1
Base of calf
B
Right:
A-D
B2
Midpoint B¹ & C
Left:
C
Right:
Right:
C
Silver
C
TG Soft
15-58 cm
®
FarrowHybridTM
Shoe size
<40 cm
40-70 cm
70-120 cm
2-5
6-8
9-11
*Supplied in pairs
Notes for FarrowHybrid: Compression in the foot. Standard foot
a = Floor
Straight distance
Heel to base of little toe
Left:
52-70 cm
A1
= 20-27cm. Wide foot
A1
12-13
= 28-35cm
X
Right:
CUSTOM-FIT PIECES
Brand/Compression
LITE (20-30mmHg)
CLASSIC (30-40mmHg)
Colour:
Beige
Quantity:
Liner options:
Additional liner quantity:
Leg:
When a footpiece and legpiece are purchased together one
pair of AD liners is inlcuded free. Please state preference^
Note: there is an extra charge for these liners.
Foot:
Left
Left
Right
Right
STRONG (30-40mmHg)
Silver
Small
Large
TG Soft
Small
Medium
Large
If none selected Silver in appropriate size will be provided.
^
Silver
Small
Large
TG Soft
Small
Medium
Large
FarrowHybrid
Small
Medium
Large
STEPS: 1. Measure the patient at all measuring points. 2. Determine if patient fits within ready-to-wear (RTW) sizing range by using the size chart. 3. If patient does not fit within a RTW,
take the additional measurements to order a custom-fit (CF) piece and send to BSN medical. 4. If patient is a RTW, complete prescription request form on reverse. 5. It is possible to mix
and match RTW and CF pieces for a patient. 6. Note: CF is not available on FP10 / GP10
Customer Service: 0845 122 3600 Compression Therapy Helpline: 0800 389 8424 Email: [email protected] www.bsnmedical.co.uk
XLarge
Request form for JOBST® Prescription Lower Limb Compression Wrap System
PLEASE ASK YOUR PATIENT TO PRESENT THIS FORM TO THEIR PRESCRIBER TO OBTAIN THE GARMENTS ON FP10 / GP10
CHOOSE BRAND/COMPRESSION LEVEL:
JOBST FARROWWRAP LITE (20-30MMHG)
Footpiece
Legpiece
JOBST FARROWWRAP CLASSIC (30-40MMHG)
BSN Code
Size
Length
Colour
PIP
76652-05
76652-00
76652-06
76652-01
76652-07
76652-02
76652-08
76652-03
76652-09
76652-04
76654-00
76654-05
76654-01
76654-06
76654-02
76654-07
76654-03
76654-08
76654-04
76654-09
Extra Small
Extra Small
Small
Small
Medium
Medium
Large
Large
Extra Large
Extra Large
Extra Small
Extra Small
Small
Small
Medium
Medium
Large
Large
Extra Large
Extra Large
Regular
Long
Regular
Long
Regular
Long
Regular
Long
Regular
Long
Regular
Tall
Regular
Tall
Regular
Tall
Regular
Tall
Regular
Tall
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
360-6332
360-6381
360-6340
360-6399
360-6357
360-6407
360-6365
360-6415
360-6373
360-6423
360-6233
360-6282
360-6241
360-6290
360-6258
360-6308
360-6266
360-6316
360-6274
360-6324
Footpiece
Legpiece
FOOTPIECE
Size
Length
Extra Small
JOBST FARROWWRAP STRONG (30-40MMHG)
BSN Code
Size
Length
Colour
PIP
76656-05
76656-00
76656-06
76656-01
76656-07
76656-02
76656-08
76656-03
76656-09
76656-04
76657-00
76657-05
76657-01
76657-06
76657-02
76657-07
76657-03
76657-08
76657-04
76657-09
Extra Small
Extra Small
Small
Small
Medium
Medium
Large
Large
Extra Large
Extra Large
Extra Small
Extra Small
Small
Small
Medium
Medium
Large
Large
Extra Large
Extra Large
Regular
Long
Regular
Long
Regular
Long
Regular
Long
Regular
Long
Regular
Tall
Regular
Tall
Regular
Tall
Regular
Tall
Regular
Tall
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
360-6688
360-6738
360-6696
360-6746
360-6704
360-6753
360-6712
360-6761
360-6720
360-6779
360-6589
360-6639
360-6597
360-6647
360-6605
360-6654
360-6613
360-6662
360-6621
360-6670
Footpiece
Legpiece
BSN Code
Size
Length
Colour
PIP
76646-04
76646-09
76646-05
76646-00
76646-06
76646-01
76646-07
76646-02
76646-08
76646-03
76648-00
76648-05
76648-01
76648-06
76648-02
76648-07
76648-03
76648-08
76648-04
76648-09
Extra Small
Extra Small
Small
Small
Medium
Medium
Large
Large
Extra Large
Extra Large
Extra Small
Extra Small
Small
Small
Medium
Medium
Large
Large
Extra Large
Extra Large
Regular
Long
Regular
Long
Regular
Long
Regular
Long
Regular
Long
Regular
Tall
Regular
Tall
Regular
Tall
Regular
Tall
Regular
Tall
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
Beige
381-9976
381-9927
382-0008
381-9950
381-9992
381-9943
381-9984
381-9935
381-9968
381-9919
382-0073
382-0024
382-0107
382-0057
382-0099
382-0040
382-0081
382-0032
382-0065
382-0016
LEGPIECE
Small
RegularLong
Medium
Large
Colour
Extra Large
Beige
Size
Length
Extra Small
Liner options:
Small
RegularTall
Medium
Colour
Large
Beige
Extra Large
When a footpiece and
legpiece are purchased
together one pair of AD
liners is inlcuded free.
Please state preference^
Silver
PIP Code:
PIP Code:
BSN Code:
BSN Code:
Quantity Required:
Quantity Required:
Small
Large
TG Soft
Small
Medium
1168/1215
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 December 2015
Repeat prescription required every
Large
months
If none selected Silver in appropriate
size will be provided.
^