SE Bracing Support 2015 - page 167

FEATURES (*standard option on DEFIANCE® III):
❏ Suede Liners/Pads
❏ Chamois Liners/Pads
❏ Swooping Thigh (not available on short thigh)*
❏ Swiveling Strap Tabs*
❏ Metal Caps - PowerCaps (recommended for contact sports)
❏ Reinforced Carbon Composite Frame
❏ High Strength Stainless Steel Gears
❏ Installed Extension Stop: 0 10 20 30 40 (circle one)
❏ Installed Flexion Stop: 45 60 75 90 (circle one)
❏ Neoprene Suspension Strap Kit
ACCESSORIES (extra charge):
❏ Full Extension Lockout Stop ❏ Floam Condyle Pad
❏ Lycra® Suspension Sleeve ❏ Armor Impact Guard
❏ Neoprene Suspension Sleeve ❏ Pinch Guard (Calf)
Sports Brace Cover ❏ Atrophy Pad Kit
❏ Sili-Grip Strap Pad Kit ❏ Tru-Pull® Advanced
❏ FourcePoint Hinge Stop Kit
BILL TO:
Account Name:__________________________________________________
Contact: _________________________ Phone: _____________________
Address: _________________________________________________________________
City:________________________________________ Zip: ____________
SHIPPING INFORMATION: ❏ Same as “BILL TO”
Name: __________________________________________________________
Address: _________________________________________________________________
FOR DJO USE ONLY:
Order #:_________________________________________________________
Brace #: _________________________________________________________
13-0723 Rev C 0539 ©2014 DJO, LLC
City:
Please note that this product is custom-made and therefore the brace is not returnable
________________________________________ Zip: ____________
PRODUCT SELECTION: CCMI Mark III
Frame: ❏ DEFIANCE® III ❏
Hinge:
❏ FourcePoint™ (ACL, LCL, MCL)
❏ Standard (ACL, PCL, MCL, LCL)
❏ DropLock (CI only)
❏ Elbow (CI only)
❏ Adjustable OA
Strapping:
OA Aƒected Compartment:
❏ ACL ❏ PCL ❏ CI
❏ Medial ❏ Lateral
Degrees of Correction: _________
DEFIANCE®
(1° to 7°) (Standard= 3°)
Note: Check both short and standard measurements for ski boot option. Best to measure with Ski Boot On.
Knee Width Lateral O¦set
————— cm
Short Calf
————— cm
Short Thigh
————— in
Standard Calf
————— in
Standard Thigh
(12½” - 38⅛”) (31.8 cm - 97 cm)
(26.125 cm - 66.5 cm) (10¼” - 26¼”)
PATIENT INFORMATION:
Name: __________________________________________________________
Age: _____________________ Height:__________Weight: ____________
Knee Measurement: ❏ Right ❏ Left ❏ Reverse
Measured By:____________________________________________________
❏ New Brace ❏ Remeasurement/Repair
❏ Comments __________________________________________________
_________________________________________________________________
NON-METALLIC COLORS:
Matte Black ❏ Neon Pink ❏ Neon Yellow ❏ Neon Orange
❏ Black ❏ Red ❏ Purple ❏ Pink
❏ White ❏ Blue ❏ Light Blue ❏ Yellow
❏ Green ❏ Orange ❏ Tan ❏ Red, White, Blue
METALLIC COLORS:
❏ Black ❏ Red ❏ Purple ❏ Pink
❏ Navy ❏ Dark Blue ❏ Bright Blue ❏ Gold
❏ Green ❏ Orange ❏ White ❏ Silver
MULTIPLE COLORS:
Thigh Frame:____________________________________________________________
Calf Frame:______________________________________________________________
Fade (non-metallic colors only): ❏ Yes ❏ No
GRAPHICS (extra charge):
❏ Tiger Red ❏ Tiger Orange ❏ Carbon Fiber
❏ Snake ❏ Camouflage
❏ Stars & Stripes (non-metallic) ❏ Stars & Stripes (metallic)
❏
❏
Fax to: +46 (0)40 39 40 99
Or scan and send to: order.nordic@djoglobal.com
Tel.:+46(0)40394000
www.DJOglobal.eu CCMI Mark III
#1 in Knee Bracing
DJO Nordic AB
Murmansgatan 126
212 25 Malmö
Sverige
Beställning
DJO Global
Defiance beställningsformulär 167