P A G E N O :
SECOND SKIN PTY LTD Existing Patient 40 O’MALLEY STREET, OSBORNE PARK 6017 (WA) P: +61 8 9201 9455 F: +61 9201 9355 New Patient E: [email protected]
PATIENT DETAILS FORM
Date: New Order (P) Reorder (P)
PATIENT: (Surname) (Given Names) Date of Birth: M £ F £ Patient Address: Post Code:
Patient Phone No: (Home) (Work)
HOSPITAL: Order Number: Hospital Address: Post Code: Therapist Name: Department: Therapist Phone No: Pager No: Therapist Email Photo Sent (P) YES NO Email POST/COURIER
My Second Skin NEW!!!! Second Skin GARMENT/ GARMENTS REQUIRED:
SEND ACCOUNT TO: (Include Claim/Reference Number)
SEND GARMENT TO: Therapist - address as above (ü) Patient- address as above (ü)
DATE REQUIRED BY:
Second Skin will always endeavour to supply this order by the date you require. Please keep in mind that delivery is subject to freight times and the receipt of written funding approval / hospital order numbers. SECOND SKIN PTY LTD 40 O’MALLEY STREET FAX: +61 8 9201 9355 P A G E N O : OSBORNE PARK 6017 (WA)
ALL IN ONE PRESCRIPTION FORM (PAGE 1 OF 2)
CLIENT SURNAME: GIVEN NAME: DATE:
Powersoft: Diagnosis: Burns Lymphoedema
Hydro/ Shimmer/ Powernet : Trauma Vascular Insufficiency My Second Skin range-feature colour (includes new active knee gusset design) Purple/Green/Pink/Blue/Yellow/White/Red (Print colour choice clearly) *NOTE: Choose one colour per garment only *Please choose carefully as garments cannot be exchanged/returned for change of mind or incorrect choice
1. Style 7. Dorsal Ankle Gusset L R Single leg Shimmer Two leg Shimmer with hydrophobic lining One and a half leg Powernet Stump support Powersoft NEW!!! Panty girdle Powernet with hydrophobic lining Flap tight Powersoft with hydrophobic lining Hernia support Single hydrophobic Scrotal support Double hydrophobic All in one (see all in one form) Centre front vertical seam 2. Fabric 8. Toes L R Powernet Closed Powersoft Shimmer Japanese toe Single hydrophobic Foot glove Double hydrophobic Stirrups 3. Crotch 9. Zips - Lower Body L R Open None in legs Closed Waist to thigh high Fly front Full length curved into foot 4. Leg Lengths Below knee - straight medial to ankle L R Below knee - straight lateral to ankle Above knee Below knee - curved medial into foot Ankle length Below knee - curved lateral into foot Including feet 10. Reinforcing L R 5. Knee Gusset L R Shimmer Posterior knee gusset - shimmer Powernet Knee flexion gusset - all shimmer Powersoft NEW!! Knee flexion gusset - powernet anterior Sole Knee flexion gusset - powersoft anterior Sole leather Knee flexion gusset - all single hydrophobic Heel Knee flexion gusset - all double hydrophobic Dorsum of foot Hydrophobic Lining - Knee Lower leg - anterior (a) anterior Lower leg - posterior (b) posterior Full leg - anterior (c) circumferential Full leg - posterior 6. Dressing Assist 11. Additional Options Zip tab Colostomy site with hole and zip access Zip looper Shaped abdomen Leather assist Pregnancy panel Soft braces with velcro closure Special requirements: Note any further design options you require. Don’t hesitate to call our design department in Perth (08 9201 9455) for any additional queries SECOND SKIN PTY LTD 40 O’MALLEY STREET FAX: +61 8 9201 9355 P A G E N O : OSBORNE PARK 6017 (WA)
ALL IN ONE PRESCRIPTION FORM (PAGE 2 OF 2)
CLIENT SURNAME: GIVEN NAME: DATE:
Powersoft: Diagnosis: Burns Lymphoedema
Hydro/ Shimmer/ Powernet : Trauma Vascular Insufficiency My Second Skin range-feature colour (includes new active axilla gusset design) Purple/Green/Pink/Blue/Yellow/White/Red (Print colour choice clearly) *NOTE: Choose one colour per garment only *Please choose carefully as garments cannot be exchanged/returned for change of mind or incorrect choice Design Options - Tick the options you require
1. Upper Body Style L R 5. Shoulder/Upper Trunk
With sleeves Splinting for postural correction Without sleeves Please send photos Stove pipe collar Bra cups 6. Hydrophobic Lining Princess line (a) Neckline Athletic top (b) Stove pipe collar (c) Armholes on sleeveless garment 2. Sleeve Length L R (d) Other - please specify below Short to elbow Long to wrist 7. Zips Upper Body None Front Back 3. Axilla Gussets L R Centre Standard (½ shimmer and ½ hydrophobic) Offset to (L) All shimmer Offset to (R) All single hydrophobic Zips in Sleeves L R All double hydrophobic None in arms Hydrophobic lining Full length arm - neckline to wrist 4. Elbow L R Upperarm - neckline to above elbow Flexion gusset Shoulder point to wrist (a) All shimmer Forearm - Radial (b) Shimmer ant & powernet post Ulnar
(c) Shimmer ant & powersoft post NEW!! Mid dorsal (d) Single hydrophobic (e) Double hydrophobic 8. Dressing Assist L R Hydrophobic Lining Zip tab (a) Anterior elbow Zip loopers (b) Circumferential elbow Leather Assist
Special requirements: Note any further design options you require. Don’t hesitate to call our design department in Perth (08 9201 9455) for any additional queries SECOND SKIN PTY LTD 40 O’MALLEY STREET FAX: +61 8 9201 9355 P A G E N O : OSBORNE PARK 6017 (WA) FEMALE VEST FORM Please F A X this form with your VEST measurement forms CLIENT SURNAME: GIVEN NAME: DATE:
Powersoft: Hydro/ Shimmer/ Powernet : My Second Skin range-feature colour Purple/Green/Pink/Blue/Yellow/White/Red (Print colour choice clearly) *NOTE: Choose one colour per garment only *Please choose carefully as garments cannot be exchanged/returned for change of mind or incorrect choice
Check List Forms you need to fax with this: KEY Patient Details Form CIRCUMFERENCE Vest Prescription Form LENGTH MEASURING TIPS FRONT VEST LENGTH MEASUREMENTS FRONT VEST > All front length measurements are taken from sterno Notch hollow i.e. base of neck (Nape), at centre front going down towards the waist. Nape > Length to be measured in centimeters to the nearest millimeter. 13 > Arms should be placed at rest by side of body. 1. Nape Drop - determines depth of neckline. 1 2. Nape to Mid Chest. 12 3. Nape to Under Breast - bra underwire level. 2 1 1 4. Nape to Waist. 3 5. Nape to End of Vest - determines vest length. 6. 6 9 4 10 7 Right Side - underarm to waist. Waist 7. Left Side - underarm to waist. 8. Underarm to end of garment. 8 5 9. End Right Side - waist up to under breast. 10. Left Side - waist up to under breast. 1 1 . Nipple to Nipple. BACK VEST 12. Armhole Crease to Armhole Crease Across Chest. Nape 6 13. Shoulder point to Shoulder point. 1
BACK VEST LENGTH MEASUREMENTS > All back length measurements are taken from C7 at centre back 2 5 (Nape) going down towards the waist. 1. Nape Drop - determines depth of neckline. 2. Nape Underarm Hole Depth. 3. Nape to Waist. 3 Waist 4. Nape to End of Vest - determines vest length. 5. Armhole to Armhole Across Back.
6. 4 Shoulder point to Shoulder point. End Page No ______FEMALE VEST MEASUREMENT FORM Patient:
MEASURING TIPS Measurements required for Bra-Cups and Princess Lines. Length measurements to All circumferences and lengths to be determine Bra-Cup position. Patient to be measured wearing a Bra. measured in centimetres to the nearest 1. millimetre. Mid Shoulder to Nipple - Left 2. Patient to be wearing a bra where Mid Shoulder over Nipple to under Breast - Left 1 and 4 possible. 3. Mid Shoulder over Nipple to Waist - Left Arms should be placed at rest by side of 4. 2 and 5 body. Mid Shoulder to Nipple - Right 5. Short sleeve lengths are determined Mid Shoulder over Nipple to under Breast - Right 3 and 6 by measuring from axilla crease down 6. Mid Shoulder over Nipple to Waist - Right to length you require sleeves to be. 7. Note this in the upperarm length to Bra Cup Size Waist elbow box.
Neck Circumference Neck to Shoulder Pt. Neck to Shoulder Pt.
Shoulder Pt. Shoulder Pt.
Neck Circumference Axilla base of neck Axilla Circumference Circumference RIGHT LEFT
Around Chest at axilla height
Around Breast Elbow Elbow
Under Breast
Elbow Elbow Mid Trunk
Waist
Hips
Styloid End of Garment Styloid Wrist Wrist Styloid Styloid Wrist KEY Wrist CIRCUMFERENCE
LENGTH
If a Stovepipe Collar is required, please take these Measurements of the Neck: Length of Neck - Determine height of collar required
4 Centre Front base of neck to collar height. 1. 2 3 1 2. Right side base of neck to collar height. Left side base of neck to collar height. 3. Centre back base of neck to collar height. 4.
1/12/2014 SECOND SKIN PTY LTD 40 O’MALLEY STREET FAX: +61 8 9201 9355 P A G E N O : OSBORNE PARK 6017 (WA) MALE AND CHILD VEST FORM Please F A X this form with your VEST measurement forms CLIENT SURNAME: GIVEN NAME: DATE: Powersoft: Hydro/ Shimmer/ Powernet : My Second Skin range-feature colour Purple/Green/Pink/Blue/Yellow/White/Red (Print colour choice clearly) *NOTE: Choose one colour per garment only *Please choose carefully as garments cannot be exchanged/returned for change of mind or incorrect choice
Check List Forms you need to fax with this: KEY Patient Details Form CIRCUMFERENCE Vest Prescription Form LENGTH MEASURING TIPS FRONT VEST LENGTH MEASUREMENTS > All front length measurements are taken from sterno Notch hollow i.e. base of FRONT VEST neck (Nape), at centre front going down towards the waist. > Length to be measured in centimeters to the nearest millimeter. Nape > Arms should be placed at rest by side of body. 13 1. Nape Drop - determines depth of neckline.
2. 1 Nape to Mid Chest. 3. Nape to Under Chest. 12 2 1 1 4. Nape to Waist. 3 5. Nape to End of Vest - determines vest length. 6. Right Side - underarm to waist. 6 9 4 10 7 Waist 7. Left Side - underarm to waist. 8. Underarm to end of garment. 9. 8 Right Side - waist up to under chest End 5 10. Left Side - waist up to under chest. 1 1 . Nipple to Nipple. BACK VEST 12. Armhole Crease to Armhole Crease Across Chest. Nape 13. Shoulder point to Shoulder point. 6 1 BACK VEST LENGTH MEASUREMENTS > All back length measurements are taken from C7 at centre back (Nape) going down towards the waist. 2 5 1. Nape Drop - determines depth of neckline. 2. Nape Underarm Hole Depth. 3. Nape to Waist. 3 4. Waist Nape to End of Vest - determines vest length. 5. Armhole to Armhole Across Back. 6. Shoulder point to Shoulder point. 4 End Page No ______MALE & CHILD VEST MEASUREMENT FORM Patient:
MEASURING TIPS All circumferences and length to be measured in centimeters to the KEY nearest millimeter. CIRCUMFERENCE
Short sleeve length are determined LENGTH by measuring from axilla crease down to length you require sleeves to end. Note: This in the upperarm length to elbow box.
Neck Circumference Neck to Shoulder Pt. Neck to Shoulder Pt.
Shoulder Pt. Shoulder Pt.
Neck Circumference Axilla base of neck Axilla Circumference Circumference RIGHT LEFT
Around Chest at axilla height
Around Breast Elbow Elbow
Under Breast
Elbow Elbow Mid Trunk
Waist
Hips
Styloid End of Garment Styloid Wrist Wrist Styloid Styloid Wrist KEY Wrist CIRCUMFERENCE
LENGTH
If a Stovepipe Collar is required, please take these Measurements: Lengths of Neck Determine height of collar required
1. Centre Front base of neck to collar height. 4 2. Right side base of neck to collar height. 2 3 3. Left side base of neck to collar height. 1 Centre back base of neck to collar height. 4. Page No ______TIGHTS MEASUREMENT FORM Patient:
If An Athletic Top is Required, for Your Tights Take These Additional Measurements 1. Sterno notch hollow (base of neck) to waist KEY 2. C7 to waist CIRCUMFERENCE 3. Full girth - see below LENGTH 4. Depth you require neckline dropped to front 5. Depth you require neckline dropped to back 6. Depth you require armholes dropped to 7. Required width of shoulder straps
Full Girth Chest Hold Tape Firmly Chest circumference is only From Sterno Notch needed if you require an Hollow thru Crutch to C7
Under Arm to L R Waist Waist Girth Hold tape firmly from front waist thru crotch to Hips back waist
Buttocks R L L L L R Inside Leg to Length R R You Require the Legs to
Knee L R Inside Leg to Back Knee Crease Mid Patella L Circumference of Dorsal Ankle Crease R L Inside Leg to Floor L R R Floor Important: Measure length of patients sole, on foot trace Above Ankle from tip of big toe to tip of heel. Mid Ankle Floor Under Ankle Instep
Metatarsals FOOT T R A C E F O R M Page No: ______DATE:______
Patient: M F
LEFT RIGHT
Grid to Scale 1:1 19 cm x 25 cm 25 x cm 19 1:1 Scale to Grid
Measuring Tips ¨ For a Japanese Toe Sock ONLY, measure big toe circumference and length. ¨ For a Foot Glove, measure all toes circumferences and lengths. TRACE OUTLINE OF FOOT ¨ Circumference measurements are taken at the middle of the toe GOING INTO ALL WEB SPACES ¨ Length measurements are taken from web space to tip of toe on the inside of as indicated on diagram with length arrow.
IMPORTANT: Measure in centimeters. Tape should be snug NOT tight. Measure to the nearest m/metre.