Date:
 

 

  Patient's Name:
  dx
  age WT HT
     

Requested

Compression:

Indications:

1

moderate

compression

approx. 25 mm Hg

  • Light edema

  • Post-treatment of burn scars

2

medium strong

compression

approx. 35 mm Hg

  • Severe post mastectomy edema

  • Post-traumatic edema

3

strong

compression

approx. 45 mm Hg

  • Very severe postoperative edema

Requested

model:

Compression sleeve

with strap

Compression sleeve with velcro to bra attachment

Compression sleeve, wrist to axilla

Hand portion with thumb stub (gauntlet)

Physician's signature and address:

Services rendered by: