Restorative Prescription THERAPIES Patient Name * First Name Last Name Date of Birth * MM DD YYYY Address * City / State / Zip * Email * Phone (###) ### #### THERAPIST * Anne Marie Amber Caitlin Heidi CONFIRMED REFERRING DOCTOR * NPI * GARMENTS REQUESTED FOR * OTS Custom Flat Fit Barton Carey Night Garments-Off the Shelf Night Garments-Custom If Custom, describe COMPRESSION LEVEL * 15/20mmHg 20/30mmHg 30/40mmHG COMPRESSION CLASS CCL I CCL II CCL III CCL IV UE Left Right Bilateral UE - Type Arm Glove Gauntlet LE Left Right Bilateral LE-TYPE Thigh High Knee High Toe Cap Full Panty Capri Bike Shorts Thank you!
