SECOND SKIN PTY LTD. 15/386 SCARBOROUGH BEACH RD, OSBORNE PARK 6017 (WA) P: F: E:

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1 Date: New Order (P) eorder (P) PATIENT: (Surname) (Given Names) Date of Birth: M F Patient Address: SECOND SKIN PTY TD 15/386 SCABOOUGH BEACH D, OSBONE PAK 6017 (WA) P: F: E: perth@secondskin.com.au PATIENT DETAIS FOM Post Code: Existing Patient New Patient Patient Phone No: (Home) (Work) HOSPITA: Hospital Address: Therapist Name: Therapist Phone No: Therapist Order Number: Post Code: Department: Pager No: Photo Sent (P) YES NO POST/COUIE My Second Skin NEW!!!! GAMENT/ GAMENTS EQUIED: Second Skin SEND ACCOUNT TO: (Include Claim/eference Number) SEND GAMENT TO: Therapist - address as above (ü) Patient- address as above (ü) DATE EQUIED 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.

2 SECOND SKIN PTY TD 15/386 SCABOOUGH BEACH D OSBONE PAK 6017 (WA) AMPUTEE OWE IMB PESCIPTION FOM CIENT SUNAME: GIVEN NAME: DATE: Powersoft: Diagnosis: Burns ymphoedema Hydro/ / : Purple/Green/Pink/Blue/Yellow/White/ed 1. Style Single leg Two leg One and a half leg Stump support Panty girdle Flap tight Hernia support Scrotal support All in one (see all in one form) 2. Fabric Powersoft Single hydrophobic Double hydrophobic 3. Crotch Open Fly front 4. eg engths Above knee Ankle length Including feet 5. Knee Gusset Posterior knee gusset - shimmer Knee flexion gusset - all shimmer Knee flexion gusset - powernet anterior Knee flexion gusset - powersoft anterior Knee flexion gusset - all single hydrophobic Knee flexion gusset - all double hydrophobic Hydrophobic ining - Knee (a) anterior (b) posterior (c) circumferential 6. Dressing Assist Zip tab Zip looper eather assist Trauma Vascular Insufficiency 7. Dorsal Ankle Gusset with hydrophobic lining Powersoft with hydrophobic lining Powersoft with hydrophobic lining Single hydrophobic Double hydrophobic Centre front vertical seam 8. Toes Japanese toe Foot glove Stirrups 9. Zips - ower Body None in legs Waist to thigh high Full length curved into foot Below knee - straight medial to ankle Below knee - straight lateral to ankle Below knee - curved medial into foot Below knee - curved lateral into foot 10. einforcing Powersoft NEW!! Sole Sole leather Heel Dorsum of foot ower leg - anterior ower leg - posterior Full leg - anterior Full leg - posterior 11. Additional Options Colostomy site with hole and zip access Shaped abdomen 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 ( ) for any additional queries

3 SECOND SKIN PTY TD 15/386 SCABOOUGH BEACH D OSBONE PAK 6017 (WA) AMPUTEE OWE IMB FOM Powersoft: Hydro/ / : CIENT SUNAME: GIVEN NAME: DATE: Purple/Green/Pink/Blue/Yellow/White/ed DESIGN OPTIONS 6 WAIST HEIGHT,one stump (. Or.) STUMP SUPPOT (below knee) STUMP SUPPOT (above knee) 3 FONT VIEW 1 SIDE VIEW 1 From Centre Front Waist Point, down eg Around Stump and Finishing at Centre Back Waistline 5 6 From Inner eg Around Stump to Waistline on ateral Side Commencement of Stump Shape from Anterior to Posterior 3 From waist to end of Stump 4 Commencement of Stump Shape from Medial to ateral Side 4 Inner eg to end of Stump Cross Section of Stump Width & ength ecommendations, Zipper ocations and Special equirements KEY CICUMFEENCE ENGTH

4 TIGHTS MEASUEMENT FOM Patient: Page No KEY CICUMFEENCE ENGTH If An Athletic Top is equired, for Your Tights Take These Additional Measurements 1. Sterno notch hollow (base of neck) to waist 2. C7 to waist 3. Full girth - see below 4. Depth you require neckline dropped to front 5. Depth you require neckline dropped to back 6. Depth you require armholes dropped to 7. equired width of shoulder straps Full Girth Chest Chest circumference is only needed if you require an Hold Tape Firmly From Sterno Notch Hollow thru Crutch to C7 Under Arm to Waist Waist Girth Hips Hold tape firmly from front waist thru crotch to back waist Buttocks Inside eg to ength You equire the egs to Mid Patella Knee Inside eg to Back Knee Crease Floor Above Ankle Mid Ankle Under Ankle Metatarsals Instep Circumference of Dorsal Ankle Crease Floor Important: Measure length of patients sole, on foot trace from tip of big toe to tip of heel. Inside eg to Floor

5 SECOND SKIN PTY TD 15/386 SCABOOUGH BEACH D OSBONE PAK 6017 (WA) Powersoft NEW!!! Hydro/ / : TIGHTS PESCIPTION FOM Please send this form with your TIGHTS measurement form CIENT SUNAME: GIVEN NAME: DATE: Purple/Green/Pink/Blue/Yellow/White/ed Check ist Forms you need to fax with this: PANTY GIDES Patient Details Form Foot Trace Form Tights/All-In-One Prescription Form Measuring Tips öthe Tights Measurement Form is used to measure for all design variation of tights, panty girdles or tights with an athletic style top. öpictured here are some of the designs available, of course there are many different variations and combinations to these designs. The patients requirements will ultimately determine th design. öall circumferences and lengths to be measured in centimetres to the nearest millimetre. Patient should be legs slightly apart. If patient is unable to stand then measure patient lying on a flat surface with feet in a 90degree position. öinside leg measurements are very important, as they determine the leg length of the tights. This is measured from inner leg at crotch to back knee crease and then to floor. If tights are not to include feet then measure to the length you require the legs to end. ie: to just above knee or to ankle. öthe girth measurement determines the height of the pant section of the tights and is measured from centre front waist thru crotch to back waist. öfull girth determines the body length for all-in-ones and is measured from sterno notch hollow thru crotch to C7. öif your patient has a muscle flap or a lower limb amputation, please use muscle flap/lower limb amputee tights form for the necessary measurements. Single eg Single eg 1 ½ egs PANTY GIDES 2 egs Open 2 egs Open 2 egs 2 egs closed ATHETIC STYE A-IN-ONES Athletic Style open 2 egs Fly Front T-Bar Style 2 egs Open Ending at Ankle Braces Fly Front

SECOND SKIN PTY LTD PATIENT DETAILS FORM. Date of Birth: M F Patient Address:

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