See product manual for warnings, precautions, and contraindications
Community medical equipment inc DBA compression medical supplies
specializing in lymphedema & venous disorders
DATE OF ORDER:
Patient Name:
DOB:
Patient Phone no:
Insurance Plan:
Insurance ID#:
Extremities for Treatment: LEGS:
LT:
RT:
With Abdomen (Lympha Pants) ARMS:
With Trunk (Comfy Sleeve)
Special request:
TREATMENT: Pressure
frequency
/Day
MIN
Length of necessity :
Months (99=Lifetime)
default settings: 40mmHg, TID/BID, 60 min
Q82.0 HEREDITARY LYMPHEDEMA
I89.0 SECONDARY LYPHEDEMA DUE TO
VENOUS INSUFFICENCY
TUMOR (S)
SCARRING OF THE LYMPH CHANNELSFROM CELLULITIS AND/OR LYMPHANGITIS
CANCER SURGERY AND/OR RADIATION
OTHER
POST MASECTOMY SYNDROME
CHRONIC VENOUS INSUFFICIENCY
Varicose vein with ulcer
Venous hypertension with an ulcer
