SECOND SKIN PTY LTD PATIENT DETAILS FORM. Date of Birth: M F Patient Address:
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1 PAGE NO: SECOND SKIN PTY TD 15/386 SCABOOUGH BEACH D, OSBONE PAK 6017 (WA) P: E: orders@secondskin.com.au or upload via (choose an order ) Date: New Order (P) eorder (P) PATIENT: (Surname) (Given Names) Existing Patient New Patient Date of Birth: F Patient Address: PATIENT DETAIS FO Post Code: 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 GAENT/GAENTS EQUIED: SEND ACCOUNT TO: (Include Claim/eference Number) SEND GAENT 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) E: orders@secondskin.com.au PAGE NO: Style Single leg Two leg One and a half leg Stump support Panty girdle Flap tight Hernia support Scrotal support A IN ONE PESCIPTION FO (PAGE 1 OF 2) CIENT SUNAE: GIVEN NAE: F DATE: Colour: Diagnosis: Burns ymphoedema Powersoft available Dark and Black only y Second Skin range-feature colour Purple/Green/Pink/Blue/Yellow/White/ed/Orange Purple/Green/Pink/Blue/Yellow/White/ed/Orange Fabric Powernet Powersoft Shimmer Single hydrophobic Double hydrophobic Crotch Open Closed Fly front eg engths Above knee Ankle length Including feet 5a. 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 5b. Hydrophobic ining - Knee (a) anterior (b) posterior (c) circumferential 6. Dressing Assist Zip tab Zip looper eather assist 7. Ankle Centre front vertical seam (preferred option) Ankle crease seam Dorsal ankle gusset: - Shimmer - Powernet - Powersoft - Single hydrophobic - Double hydrophobic - Hydrophobic lining 8. Toes Closed Japanese toe Foot glove Stirrups 9. Zips - ower Body None in legs 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 Shimmer Powernet Powersoft Sole Sole leather Heel Dorsum of foot ower leg - anterior Trauma ower leg - posterior Full leg - anterior Full leg - posterior 1 Additional Options Colostomy site with hole and zip access Shaped abdomen Pregnancy panel Soft braces with velcro closure Vascular Insufficiency eft (Print colour choice clearly) ight (Print colour choice clearly) Choose one colour per garment only *Please choose carefully as garments cannot be exchanged/returned for change of mind or incorrect choice Note any further design options you require. Call our design department in Perth ( ) for any queries
3 SECOND SKIN PTY TD 15/386 SCABOOUGH BEACH D OSBONE PAK 6017 (WA) E: orders@secondskin.com.au PAGE NO: A IN ONE PESCIPTION FO (PAGE 2 OF 2) CIENT SUNAE: GIVEN NAE: F DATE: Colour: Diagnosis: Burns ymphoedema Powersoft available Dark and Black only y Second Skin range-feature colour Purple/Green/Pink/Blue/Yellow/White/ed/Orange Purple/Green/Pink/Blue/Yellow/White/ed/Orange Trauma Vascular Insufficiency eft (Print colour choice clearly) ight (Print colour choice clearly) Choose one colour per garment only *Please choose carefully as garments cannot be exchanged/returned for change of mind or incorrect choice Upper Body Style With sleeves Without sleeves Stove pipe collar Bra cups Princess line Athletic top ength to elbow ong to wrist None Gussets Standard (½ shimmer and ½ hydrophobic) All shimmer All single hydrophobic All double hydrophobic Hydrophobic lining 4a. Flexion gusset (a) All shimmer (b) Shimmer ant & powernet post (c) Shimmer ant & powersoft post NEW!! (d) Single hydrophobic (e) Double hydrophobic 4b. Hydrophobic ining (a) Anterior elbow (b) Circumferential elbow 5. Shoulder/Upper Trunk Splinting for postural correction Please send photos 6. Hydrophobic ining (a) Neckline (b) Stove pipe collar (c) Armholes on sleeveless garment (d) Other - please specify below 7a. Zips Upper Body Front Back Centre Offset to () Offset to () 7b. Zips in s None in arms Full length arm - neckline to wrist Upperarm - neckline to above elbow Shoulder point to wrist 7c. Forearm - adial Ulnar id dorsal 8. Dressing Assist Zip tab Zip loopers eather Assist Note any further design options you require. Call our design department in Perth ( ) for any queries
4 SECOND SKIN PTY TD 15/386 SCABOOUGH BEACH D OSBONE PAK 6017 (WA) E: orders@secondskin.com.au PAGE NO: A IN ONE VEST PESCIPTION FO CIENT SUNAE: GIVEN NAE: F DATE: FONT VEST ENGTH EASUEENTS Ÿ Ÿ All front length measurements are taken from sterno notch hollow at base of neck (nape), at centre front going down towards the waist. Arms should be placed at rest by side of body Nape Drop - determines depth of neckline Nape to level - left Nape to level - right Nape to id Chest. Nape to Under Breast - bra underwire level Nape to. Nape to End of Vest - determines vest length ight Side - underarm to waist eft Side - underarm to waist Underarm to end of garment ight Side - waist up to under breast eft Side - waist up to under breast Nipple to Nipple Armhole Crease to Armhole Crease Across Chest Shoulder point to Shoulder point BACK VEST ENGTH EASUEENTS Ÿ All back length measurements are taken from C7 at centre back (nape) going down towards the waist Nape Drop - determines depth of neckline Nape to - left Nape to - right Nape to Nape to End of Vest - determines vest length Armhole to Armhole Across Back Shoulder point to Shoulder point
5 AIO FEAE VEST EASUEENT FO Client: Page No easurements required for Bra-Cups and Princess ines. ength measurements to determine Bra-Cup position. Patient to be measured wearing a bra id Shoulder to Nipple - eft id Shoulder over Nipple to under Breast - eft id Shoulder over Nipple to - eft id Shoulder to Nipple - ight id Shoulder over Nipple to under Breast - ight id Shoulder over Nipple to - ight Bra Cup Size 1 and 4 2 and 5 3 and 6 KEY CICUFEENCE ENGTH IGHT Shoulder Pt. Neck to Shoulder Pt. Circumference Neck Circumference Neck Circumference base of neck Neck to Shoulder Pt. Circumference Shoulder Pt. EFT Around Chest Around Breast at axilla height Under Breast id Trunk Hips Wrist Crease End of Garment Wrist Crease Wrist Crease Wrist Crease If a Stovepipe Collar is required, please take these easurements: Height of Neck Collar Centre Front base of neck to collar height. ight side base of neck to collar height. eft side base of neck to collar height. Centre back base of neck to collar height
6 AIO AE & CHID VEST EASUEENT FO KEY CICUFEENCE Client: Page No ENGTH Neck Circumference Neck to Shoulder Point Neck to Shoulder Point Shoulder Point Shoulder Point IGHT Circumference Neck Circumference base of neck Circumference EFT Around Chest Around Breast at axilla height Under Breast id Trunk Hips Wrist Crease End of Garment Wrist Crease Wrist Crease Wrist Crease If a Stovepipe Collar is required, please take these easurements: Height of Neck Collar Centre Front base of neck to collar height. ight side base of neck to collar height. eft side base of neck to collar height. Centre back base of neck to collar height
7 AIO TIGHTS EASUEENT FO Client: Page No Girth Tally Check Add Front - Nape to + Back - Nape to + Half Girth = Total (must be within 1-2cm of full girth) If an Athletic top is required for your tights, take these additional measurements Front - Nape (sterno notch) to Back - Nape (C7) to waist Full girth - see below Depth you require neckline dropped at the front Depth you require neckline dropped at the back Depth you require armholes dropped to Width of shoulder straps required Hips Sterno Notch C7 Full Girth Buttocks Hold tape firmly from Sterno Notch Hollow thru Crutch to C7 Half Girth Hold tape firmly from front waist thru crotch to back waist Knee Crease Knee Inside leg to back knee crease To Floor etatarsals Instep Dorsal Ankle Crease Under Ankle Ab ov e A nk id Ank le le Floor Inside leg to required length Inside leg to floor Instep etatarsals
8 Grid to Scale 1:1 19 cm x 25 cm FOOT T A C E F O Page No: DATE: Client: F EFT IGHT TACE OUTINE OF FOOT GOING INTO A WEB SPACES easuring Tips Important: easure length of clients sole on foot trace from tip of big toe to tip of heel. =For Japanese Toe, measure big toe circumference and length. =For a Foot Glove measure all toe circumferences and lengths =Circumference measurements are taken at the middle of toe. =ength measurements are taken from web space to tip of toe on the side of the toe as indicated with length arrow.
SECOND SKIN PTY LTD PATIENT DETAILS FORM. Date of Birth: M F Patient Address:
PAGE NO: SECOND SKIN PTY TD 15/386 SCABOOUGH BEACH D, OSBONE PAK 6017 (WA) P: +61 8 9201 9455 E: orders@secondskin.com.au or upload via www.secondskin.com.au/contact/enquiry (choose an order ) Date: New
More informationSECOND SKIN PTY LTD PATIENT DETAILS FORM. Date of Birth: M F Patient Address:
PAGE NO: SECOND SKIN PTY TD 15/386 SCABOOUGH BEACH D, OSBONE PAK 6017 (WA) P: +61 8 9201 9455 E: orders@secondskin.com.au or upload via www.secondskin.com.au/contact/enquiry (choose an order ) Date: New
More informationSECOND SKIN PTY LTD PATIENT DETAILS FORM. Date of Birth: M F Patient Address:
PAGE NO: SECOND SKIN PTY LTD 15/386 SCARBOROUGH BEACH RD, OSBORNE PARK 6017 (WA) P: +61 8 9201 9455 E: orders@secondskin.com.au or upload via www.secondskin.com.au/contact/enquiry (choose an order ) Date:
More informationSECOND SKIN PTY LTD. 15/386 SCARBOROUGH BEACH RD, OSBORNE PARK 6017 (WA) P: F: E:
PAGE NO: Date: New Order (P) Reorder (P) PATIENT: (Surname) (Given Names) Date of Birth: M F Patient Address: SECOND SKIN PTY LTD 15/386 SCARBOROUGH BEACH RD, OSBORNE PARK 6017 (WA) P: +61 8 9201 9455
More informationSECOND SKIN PTY LTD. 15/386 SCARBOROUGH BEACH RD, OSBORNE PARK 6017 (WA) P: F: E:
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: +61 8 9201 9455 F: +61 9201 9355
More informationSECOND SKIN PTY LTD. 15/386 SCARBOROUGH BEACH RD, OSBORNE PARK 6017 (WA) P: F: E:
PAGE N: Date: New rder (P) Reorder (P) PATIENT: (Surname) (Given Names) Date of Birth: M F Patient Address: SECND SKIN PTY LTD 15/386 SCARBRUGH BEACH RD, SBRNE PARK 6017 (WA) P: +61 8 9201 9455 F: +61
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