SECOND SKIN PTY LTD. 15/386 SCARBOROUGH BEACH RD, OSBORNE PARK 6017 (WA) P: F: E:
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1 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: F: E: perth@secondskin.com.au PATIENT DETAILS FRM Post Code: Existing Patient New Patient Patient Phone No: (Home) (Work) HSPITAL: Hospital Address: Therapist Name: Therapist Phone No: Therapist rder Number: Post Code: Department: Pager No: Photo Sent (P) YES N PST/CURIER My Second Skin NEW!!!! GARMENT/ GARMENTS REQUIRED: Second Skin SEND ACCUNT T: (Include Claim/Reference Number) SEND GARMENT T: 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.
2 SECND SKIN PTY LTD 15/386 SCARBRUGH BEACH RD SBRNE PARK 6017 (WA) PAGE N: GLVE/MCP/GAUNTLET PRESCRIPTIN FRM Please FAX this form with your GLVE/MCP/GAUNTLET measurement forms Powersoft: Diagnosis: Burns Lymphoedema Hydro/ Shimmer/ Powernet : My Second Skin range-feature colour Trauma Vascular Insufficiency Left Glove (Print colour choice clearly) Right Glove (Print colour choice clearly) *NTE: Choose one colour per garment only *Please choose carefully as garments cannot be exchanged/returned for change of mind or incorrect choice Design ptions - Tick the options you require 1. Style L R Glove - includes fingers MCP Gauntlet - web spacers Gauntlet - ends at MCP 5. Finger Tips L R pen Closed Mixed 2. Fabric L R Powernet Powersoft Shimmer Single hydrophobic Double hydrophobic 6. Leather Reinforcing L R Palm Thumb Fingers Forearm No leather at base of fingers 3. Zips L R None Ulnar Radial Mid Dorsal 7. Thumb Position L R Standard - in neutral position Rotated for opposition to index finger De-rotation - stretched away from palm Dual 8. Dressing Assist 4. Finger Gussets L R Standard Slant inserts Zip tab Zip looper Leather Assist Finger web spacers - for MCP Gauntlet only Special requirements: Note any further design options you require. Don t hesitate to call our design department in Perth ( ) for any additional queries
3 SECND SKIN PTY LTD 15/386 SCARBRUGH BEACH RD SBRNE PARK 6017 (WA) PAGE N: Powersoft: Hydro/ Shimmer/ Powernet : My Second Skin range-feature colour MCP MEASUREMENT FRM - RIGHT Right Glove (Print colour choice clearly) *NTE: 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: Patient Details Form Hand Trace Glove Prescription Form Hand Assessment Form Measuring Tips All circumferences and lengths to be measured in centimetres to the nearest millimetre. Hand posture as flat as possible. Tape should be snug not tight. Determine the length of gauntlet, Measurement No.1 by measuring from Styloid Wrist (anatomical), proximally down the arm to the length you require the MCP gauntlet to end. We recommend a minimum of 8cm for Adults, 3cm for Children. Arm circumference measurements No. 2, 3, 4 and 5 are measured at equidistances between Styloid Wrist and end of MCP gauntlet. If length of gauntlet is short you may not be able to include 3 x circumference measurements in between wrist to end. Hand length measurements No. 6, 7 and 8 are measured on the palmar surface of the hand from Styloid Wrist up to mid MCP joint ie: to required distal end of MCP gauntlet. Depth of thumb web crease measurement No.9 is measured from index web squared down to level with thumb crease on palmar surface. MCP circumference is measured around the MCP Joints. Finger circumferences are measured at the base of the finger - as indicated. PEN CLSED Thumb circumference is measured at IP joint - as indicated. Length of thumb measurements No.14 is measured from thumb crease to length you require thumb to end. This is standardly to base of nail bed or to tip of thumb if closed tip is required Elbow Styloid Wrist 1 End of Glove KEY CIRCUMFERENCE LENGTH
4 Grid to Scale 1:1 19 cm x 25 cm H A N D T R A C E F R M Page No: DATE: Patient: M F Spread Fingers to trace Around IMPRTANT: Measure in centimeters. Tape should be snug NT tight. Measure to the nearest m/metre.
5 SECND SKIN PTY LTD 15/386 SCARBRUGH BEACH RD SBRNE PARK 6017 (WA) PAGE N: GLVE/MCP/GAUNTLET ASSESSMENT FRM Please FAX this form with your GLVE/MCP/GAUNTLET measurement forms Hand Assessment Form Left Dorsal Left Palmar Right Palmar Right Dorsal INDICATE AREA F INJURY R TRAUMA DMINANCE: LEFT RIGHT
SECOND 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
SECOND 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:
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
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
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
SECOND 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
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