NOTE: DO NOT SEND MEASURING TAPES IF PATIENT HAS INFECTIOUS DISEASE OR IF TAPES ARE CONTAMINATED WITH BODY FLUIDS.

Torbot Custom Compression

JOBSKIN COMPRESSION GARMENT For Burnscar Management and Scar Hypertrophy

Email JobskinCS@JobskinGarments.com or fax completed order forms to 800-207-1579

1

PO #

2

3

HOTLINE

TORBOT GROUP PATIENT NUMBER (reorders only)

PATIENT

DOB (mm/yyyy)SEX

LAST NAME FIRST NAME

ZIP CODE

ADDRESS CITY STATE

COUNTRY- PHONE

Original Exact Reorder Reorder with Changes

DATE:

ZIP CODE

LAST NAME FIRST NAME

ADDRESS CITY STATE

- COUNTRY

PRESCRIBER

ID#

COMPRESSION: Burn Standard (15-30 mmHg) Other:_________ (burn standard used if blank)

Order Type

DIAGNOSIS: Burn Survivor Scar Management

Guaranteed to ship in 3 business days (additional cost)

4 MEASURED BYNAME FACILITY

EMAILPHONE FAX

5SHIP TO

ZIP CODE

ADDRESS CITY STATE

COUNTRY- PHONE

FAX

6

ZIP CODE

ADDRESS CITY STATE

COUNTRY PHONE

BILL TO ATTN FAX

EMAIL

ATTN

Page 1 of 7

-

W/O

7 LOWER EXTREMITIES LEG CIRCUMFERENCES

If spine of measuring device was pleated, give center-to-center distance between those tapes in eighths. All measurements in 1/8in units. Enter inches and 1/8ths for all. EXAMPLE: = 12 6/8" = 7 3/8"

71/2

6

41/2

3

11/2

Heel 0

11/2

3

41/2

6

71/2

9

101/2

12

131/2

15

161/2

18

191/2

21

221/2

24

251/2

27

281/2

30

311/2

33

341/2

36

PLEATS PLEATSLEFT RIGHTTAPE#

__

Pleat at end of

foot only (max 2)

__

Pleat at top

only (max 1)

__

8 STYLES CAT# Qty Left

Qty Right

Qty Other

PRICE EACH TOTAL

Anklet 0105

Knee Length 0101

Thigh Length 0201

Waist Height, Two Legs, Closed Pubis 1101

Waist Height, Two Legs, Open Pubis 1102

Waist Height, One Leg, Open Pubis 1103

Waist Height, One Leg Panty, Closed Pubis 1113

Panty Girdle, Two legs, Above Knee, Closed Pubis 1119

Panty Girdle, Two Legs, Below Knee, Closed Pubis 1111

Panty Girdle, Two Legs, Below Knee, Open Pubis 1110

9 OPTIONS CAT# Qty Left

Qty Right

Qty Other

PRICE EACH TOTAL

Reinforced Heel (per leg) 1187

Reinforced Knee (per leg) 1186

Lining Behind Knee (per leg) 0040

Self-material Enclosed Toes (mark foot lengths at comments) 1159

Soft Material Enclosed Toes 1160

Zipper (each opening). Mark location below in zipper options 1164

Velcro Tabs for Vest Attachment (set of 4) 1163

Oversize Charge (If largest circumference measurement is 50 - 59" (127 - 151 cm)

1177

If largest circumference measurement is 60-69"(152 - 177 cm) 0031

If Largest circumference measurement is 70-79" (178-201 cm) 0042

Contracture Seam 0176

1" Silicone Band 1118

2" Silicone Band 0160Attached Suspenders (Children under 3 n/c) 0090

Attached Suspenders 1162

10 SUBTOTAL

ZIPPER OPTIONS Full length zipper is standard for burns (Vascular=10inches). If shorter zipper is desired, provide length in whole inches.

LOCATION (X) LENGTH (inches)

LEFT RIGHT LEFT RIGHT

LATERAL (outside) ASPECT (std.)

MEDIAL (inside) ASPECT

IN BODY ONLY (begins at top)SEE PRICE LIST FOR CATALOG NUMBER(S) OF ADDITIONAL STYLES AND OPTIONS. WAIST HEIGHT GARMENTS REQUIRE MEASUREMENTS 1-9 ON PAGE 3. Page 2 of 7

Comments

W/O

Page 3 of 7

11 TORSO Note: A prefix of 5911 will be added to all Burn catalog #'s and 5917 will be added to all Vascular catalog #'s.

STYLES CAT# Qty PRICE EACH TOTAL REQUIRED

MEASUREMENTS

Vest, sleeveless* 0525 1; 10-14;17

Vest, 1 long sleeve and 1 short sleeve* 0524 1; 10-14; 17; arm(s)

Vest, 2 short sleeves* 0526 1; 10-14; 17; arm(s)

Vest, 2 long sleeves* 0527 1; 10-14; 17; arm(s)

Body Brief, sleeveless 0530 1; 5; 7; 9-17

Body Brief, with sleeves 0531 1; 5; 7; 9-17; arm(s)

Bodysuit, sleeveless with legs 0558 1; 5; 7; 9-17; leg(s)

Bodysuit, with sleeves and legs 0560 1; 5; 7; 9-17; arm(s);

leg(s);

12 Subtotal

14 OPTIONS CAT# Qty PRICE EACH TOTAL

Reduced Pressure Abdominal Panel 1161

Velcro Tabs for Vest Attachment (set of 4) 1163Reinforced Inner Thigh & Perineum (Bodysuit only) 1185Oversize Charge If largest circumference is 50-59" (127-151 cm) 1177Oversize Charge If largest circumference is 60-69" (152-177 cm) 0031

Oversize Charge If largest circumference is 70-79" (178-201 cm) 0042

1" Silicone Band 1118

2" Silicone Band 0160

15 Subtotal

16 DESIGN CHOICES

Front Closure Zipper

Front Closure Velcro

Back Closure Zipper

Back Closure Velcro

Open Axilla LT RT

Meshed Axilla LT RT

Self Axilla LT RT

Turtleneck

Scoop Neck

V Neck

If arm or leg measurements are required, go to 7 (leg), or 17 (arm). If options are required, go to 9 (leg), or 19 (arm).

Comments

13 TORSO/BODY MEASUREMENTS CIRCUMFERENCE HEIGHT

Desired Top of Support

Waist 1 2

Midpoint between 1 and 5 3 4

Largest Part of Buttocks 5 6

Proximal Thigh Left (at fold of buttocks) 7 8

Proximal Thigh Right (at fold of buttocks) 9 8

Left Shoulder 10

Right Shoulder 11

Neck 12

Shoulder Width 13

Shoulder to Waist 14

Shoulder to Largest Part of Buttocks 15

Shoulder to Fold of Buttocks 16

Chest 17

ADDITIONAL MEASUREMENTS FOR BRA CUPS

Shoulder to Just Under Breast A

Circumference Just Under Breast B

Circumference Over Nipple Line C

* VEST BELOW WAIST

Shoulder to End of Support

Circumference at End of Support

W/O

20 ZIPPER LENGTH Full length zipper is standard. If shorter zipper is desired, please indicate length from wrist in whole inches.

ARM CIRCUMFERENCES If spine of measuring tape was pleated, give center-to-center distance between tapes only at axilla, wrist, and gauntlet. All measurements in 1/8in units. Enter inches and 1/8ths for all. Enter elbow measurements beside box marked "Elbow" (Tape#9). EXAMPLE: = 12 6/8" = 7 3/8"

17 ARM

4 1/2

3

1 1/2

0

1 1/2

3

4 1/2

6

7 1/2

Elbow 9

10 1/2

12

13 1/2

15

16 1/2

18

19 1/2

PLEATS PLEATSLEFT RIGHTTAPE#

18 STYLES CAT# Qty Left

Qty Right

PRICE EACH TOTAL

Forearm Sleeve (wrist to elbow) 0515

Forearm Sleeve with Gauntlet (metacarpals to elbow) 0516

Arm Sleeve (wrist to axilla) 0501

Arm Sleeve with Attached Shoulder Flap 0503

Arm Sleeve with Attached Gauntlet (metacarpals to axilla) 0502

Detachable Gauntlet 0505

19 OPTIONS CAT# Qty Left

Qty Right

PRICE EACH TOTAL

Zipper (each opening) Mark Length at (20) 1164

Lining Inside Elbow 1167

Lining Full Elbow 1168

Adjustable ShoulderFlap (see 22) 1172

Contracture Seam 0176

1" Silicone Band 1118

2" Silicone Band 0160

23 Subtotal

LOCATION (x) LENGTH (in inches)

LEFT RIGHT LEFT RIGHT

Standard zipper - Lateral (radial) (outside)Aspect

Medial (ulnar) (inside) Aspect

Posterior (back of hand)

Anterior (palm of hand)

21 GAUNTLET

Circumference of Thumb

Left Right

Desired Thumb Length

Left Right

Thumb Open Tip

Yes No

22 SHOULDER FLAP

SHOULDER FLAP length diagonally from top

of shoulder to waist or below breast

Left Right

Provide circumference at waist or below breast if adjustable flap is requested

COMMENTS

W/O Page 4 of 7

Page 5 of 7

25 GLOVE OPTIONS CAT# Qty Left

Qty Right

PRICE EACH TOTAL

Slant Inserts 1169

1" Silicone Band 1118

2" Silicone Band 0160

Zipper (each opening) Mark location below 1164

Zipper Location (Mark [X]) Ulnar (little finger)(STANDARD))

Zipper Location (Mark [X]) Dorsal (Posterior)

Zipper Location (Mark [X]) Palmar (Anterior)

open tip(s)

[X]Left *Lengths Right

open tip(s)

[X]

12-Little finger to web between little and ring fingers.

13-Ring finger to web between ring and middle fingers.

14-Middle finger to web between middle and index fingers.

15-Index finger to web between middle and index fingers.

16-Thumb to thumb web.

17-Wrist to web between little and ring fingers.

18-Wrist to web between middle and ring fingers.

19-Wrist to web between index and middle fingers.

20-Wrist to thumb web.

24 GLOVE STYLES CAT# Qty Left

Qty Right

PRICE EACH TOTAL

Glove to Wrist 0535

Glove to Elbow 0534

Interdigital Web Spacer (worn over glove) 0536

27 CIRCUMFERENCE

Left Circumference Right

1-Little Finger DIP

2-Little Finger PIP

3-Ring Finger DIP

4-Ring Finger PIP

5-Middle Finger DIP

6-Middle Finger PIP

7-Index Finger DIP

8-Index Finger PIP

9-Thumb IP

10-Palm

11-Wrist

1 1/2" Beyond Wrist

3" Beyond Wrist

IMPORTANT - COMPLETED HAND OUTLINE WITH SCALE IS REQUIRED * Open Tip Glove length measurement is finished length desired.

26 Subtotal

28 HEAD STYLES CAT# Qty PRICE EACH TOTAL

Face Mask 0540

Face Mask, Open Face 1158

Chin Strap 0550

Chin Strap, Modified (extends behind ear) 0549

29 HEAD OPTIONS CAT# Qty PRICE EACH TOTAL

Lip Covering 1166

Nose Covering 1165

30 Subtotal

31 HEAD MEASUREMENTS

Masks/Chin Straps Measurement

1-Width of Eyes

2-Length of Ear

3-Width of Mouth

4-Chin to Eyes

5-Chin to Mouth

6-Circ. above Eyebrow

7-Around Head at Chin Angle

8-Circ. of Neck

Measurement (use only if ordering a nose cover)

A-Across Tip of Nose

B-Length of Nose

COMMENTS

W/O

Page 6 of 7W/O

CUSTOM ORDER SKETCH PAD

Patient Name

Torbot Patient #

Date

Fig. 1 Fig. 2

Fig. 3 Fig. 4

Use this sketch pad to draw , or mark the locations of special linings and any other feature that cannot be indicated on the order form. Please use a dark pen or pencil and clearly mark the area as legibly as possible. Be sure to provide measurements indicating exact size and locations of requested items. IMPORTANT INDICATIONS FOR SILON 1) Do NOT request silon be added to more than 50% of your garment. Compression cannot be guaranteed or reliable when a garment contains that volume of silon. 2) We recommend zippers for garments containing silon to make the garment easier to put on and take off. If possible, print this page and sketch your locations. Then fax the form to us. If ordering electronically, please describe locations in detail.

Torbot Fax

Torbot Customer Service

Comments

ACCUMULATED SUBTOTALS

Subtract 10% of Subtotals for Children Under Age 6

Add Hot-Line Service Fee - 30% of Subtotals (if applicable)

Shipping Fee

International Shipping Fee

Minimum Handling Fee (if applicable) (see price list)

TOTAL

NOTICE: WE DO NOT ACCEPT THIRD PARTY BILLINGS

FOR TORBOT GROUP, INC., USE ONLY

SALES ORDER

PATIENT

PRESCRIBER

SHIP TO

BILL TO

P.O.

ID

PACKED BY

QUANTITY

Warranty in general Torbot Group-Jobskin Division will replace any problem compression garment for fit and workmanship, free of charge, within 30 calendar days (Warranty Period) of being shipped from our manufacturing facility. As soon as a problem is identified to The Torbot Group, another garment will be manufactured at our discretion. If this is the case a replacement will be manufactured immediately. We will not wait until the problem garment is returned (unless the problem cannot be determined without seeing the garment). Any problem garment shall be returned to Torbot Group as soon as possible. Please provide as much information as possible so that we can conduct a full investigation. Without the return of the garment, it is difficult to determine the exact nature of the problem and find a remedy. All returned garments must be clean/laundered to minimize any potential risk of infection. Torbot Group is unable to accept any garment that is not clean when returned and such garments may be destroyed immediately. If the replacement garment requires significantly different measurements, the replacement garment will generally be treated as a reorder.

Remittance to: Torbot Group, Inc., Jobskin Div. 5030 Advantage Dr. , Suite 101 Toledo, Oh 43612

Signature ________________________________________

Credit Card

Exp. Date /

Security Code

PLEASE CHARGE TO MY

Page 7 of 7

Jobskin Customer Service: Torbot Group Inc., Jobskin Division 5030 Advantage Drive, Suite 101 Toledo, Ohio 43612 Fax: 800.207.1579 or 419.724.1476/1477 Phone: 800.207.1074 or 419.724.1478

Torbot Group Inc. - World Class Compression Garments World Class Ostomy Products Thank You for Your Purchase!

W/O