Fusion XT Fusion Fusion Womens Fusion Womens White Fusion Lateral NA S

Fusion XT   Fusion   Fusion Womens   Fusion Womens White   Fusion Lateral NA  S Fusion XT   Fusion   Fusion Womens   Fusion Womens White   Fusion Lateral NA  S - Start

2015-03-20 273K 273 0 0

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com wwwbregcom BILL TO Customer P0 Contact Tel Name Address City State Zip SHIP TO if different Name Address City State Zip FOR OFFICE USE ONLY PATIENT INFORMATION LEG MEASUREMENTS 1 Thigh Circumference 2 C alf Circumference 3 Knee ID: 47894 Download Pdf

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Fusion XT Fusion Fusion Womens Fusion Womens White Fusion Lateral NA S




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Presentations text content in Fusion XT Fusion Fusion Womens Fusion Womens White Fusion Lateral NA S


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Fusion XT 01200 01226 Fusion 01207 01221 Fusion Womens 01201 01223 Fusion Womens White 01203 01224 Fusion Lateral N/A 01302 Solus N/A 19104 LPR 00028 N/A Fusion XT Color 01215 01227 Fusion Color 01209 01222 Fusion Women Color 01214 01225 Fusion Lateral Color N/A 01303 Solus Color N/A 19105 LPR Color 00029 N/A *72 hr turnaroun d on Fusion custom Pantone / custom pattern orders NOTES/SPECIAL INSTRUCTIONS aturday Next Day Early AM Next Day AM Next Day PM 2nd Day 3rd Day Ground UPS Fed Ex No Charge DATE/TIME: ______________________ TAKEN BY: _______________________ ORDER #: ________________________ RA #: ____________________________ NEW ACCOUNT HOT Custom Knee Brace Order Form Phone: (8 00) 321-0607 Fax: (800) 329-2734 Email: orderprocess@breg.com www.breg.com BILL TO Customer # ____________________ P0 # ___________________ Contact ________________________ Tel # ___________________ Name __________________________________________________ Address ________________________________________________ City ___________________________ State ______ Zip _________ SHIP TO (if different) Name __________________________________________________ Address ________________________________________________ ________________________________________________________ City ___________________________ State ______ Zip _________ FOR OFFICE USE ONLY PATIENT INFORMATION LEG MEASUREMENTS 1. Thigh Circumference 2. C alf Circumference 3. Knee Offset . Knee Width Measurements taken by: ___________________________ Extension: 0˚ *10˚ 20˚ 30˚ 40˚ Flexion: 45˚ 60˚ 75˚ 90 *New braces ship with 10˚ extension stops installed. FUSION BRACE INFORMATION SHIP VIA Unless specified UPS 2nd Day will be used Sl ide Guar d, M/L (22000) Slide Guard, XL/XXL (22001) Cotton Undersleeve (0985X) Neoprene Undersleeve (0735X) Fusion Brace Cover (1008X) Silicon Strap (75070) Patella Cup (70058) FUSION FRAME PADS  2013 Breg, Inc. All rights reserved. Fusion is a registered trademark of Breg, Inc. AW-1.00717 REV A 1213 Standard Hinge *OA Plus Forest Royal Red Orange Yellow Charcoal Navy Sage Mauve Pink Custom Flames Flag Ripples amouflage Custom Pattern* Notes: ______________________________ All Fusion braces available with black frame pads only. Bilat Cast Reform FUSION ACCESSORIES Pantone*_________ Color Patients Name: _________________________________________ Age: _____ Weight: _____ Height: _____ Sex: M F BRACE FOR: Left Leg Right Leg INSTABILITY: ACL PCL MCL/LCL OA Unloading: Medial (Fusion/Solus) Lateral (Fusion Lateral) Pattern Additional charge for color or pattern Color Enhancement (03161) Pattern Enhancement (03162) Custom Color/Pattern (03163) FOR OFFICE USE ONLY breg.com/kneekit Scan for instructional video
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DATE/TIME: ______________________ TAKEN BY: _______________________ ORDER #: ________________________ RA #: ____________________________ NEW ACCOUNT HOT Custom Knee Brace Order Form Phone: (8 00) 321-0607 Fax: (800) 329-2734 www.breg.com BILL TO Customer # ____________________ PO # ___________________ Contact ________________________ Tel # ___________________ Name __________________________________________________ Address ________________________________________________ City ___________________________ State ______ Zip _________ SHIP TO (if different) Name __________________________________________________ Address ________________________________________________ ________________________________________________________ City ___________________________ State ______ Zip _________ FOR OFFICE USE ONLY Patients Name: _________________________________________ Age: _____ Weight: _____ Height: _____ Sex: M F BRACE FOR: Left Leg Right Leg INSTABILITY: ACL PCL MCL/LCL CounterForce*: OA - Medial Unloading ________ OA - Lateral Unloading ________ PATIENT INFORMATION LEG MEASUREMENTS 1. Thigh Circumference 2. C alf Circumference 3. Knee Offset . Knee Width Measurements taken by: ___________________________ Extension: 0˚ *10˚ 20˚ 30˚ 40˚ Flexion: 45˚ 60˚ 75˚ 90 *New braces ship with 10˚ extension stops installed. X2K BRACE INFORMATION aturday Next Day Early AM Next Day AM Next Day PM 2nd Day 3rd Day Ground UPS Fed Ex No Charge SHIP VIA Unless specified UPS 2nd Day will be used  2013 Breg, Inc. All rights reserved. X2K is a registered trademark of Breg, Inc. AW-1.00717 REV A 1213 PTO w/ Adj Hinge 20025 20029 20033 20037 20056 Brace Bag (70057) Patella Cup (70058) Cotton Undersleeve (0985X) Neoprene Undersleeve (0735X) X2K Brace Cover (1099X) WX2K/CX2K Brace Cover (1008X) Silicon strap (75070) Bilat Cast Reform ACCESSORIES X2K X2K HP Wrinklecoat Womens X2K Compact X2K Compact X2K HP Wrinklecoat *COUNTERFORCE PLUS OPTION NOT AVAILABLE ON PTO Standard Hinge 20001 20007 20013 20019 20051 Adjustable Hinge 20002 20008 20014 20020 20052 *Counterforce Plus 20003 20009 20015 20021 20053 NOTES/SPECIAL INSTRUCTIONS Scan for instructional video breg.com/kneekit

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