New order/request – Chronic Oedema Solutions

Compression Order/Request

Complete the following form to place an order or request a quote. If you are unsure at any stage, click the BACK TO ORDER PAGE button to request help

Please provide a delivery address where the therapist can receive the order.

Deliver to: *

Delivery address line 1 *

Delivery address line 2

Suburb

State

Postcode

Your email *

Your phone number *

For a copy of this order to be sent to your Case Manager, please add their details below.

Case Manager Name *

First

Last

Case Manager Email *

Any additional comments for the Case Manager

Who is paying for this order? *

Organisation
Client

Who needs to receive a copy of the invoice? *

Organisation Accounts Department
Care Manager
Client/Client Representative

When the order is despatched, the delivery notification will be sent by email to: *

What are you requesting? *

Order
Approval for Order

Client name *

First

Last

Client/Client Representative email *

Client/Client Representative phone number *

Pertex Light

Do you need Pertex Light Below Knee compression garments? *

How many pairs of Pertex Light below knww compress garments do you need? *

Grip top *

Does the client need different size garments for each leg *

Please tick the box to make your selection

Pertex Light Below Knee Compression Garment NO grip top (1 pair)

Pertex Light Below Knee Compression Garment NO grip top (1 pair) - $130.00

Pertex Light Below Knee Compression Garment NO grip top (2 pairs)

Pertex Light Below Knee Compression Garment NO grip top (2 pairs) - $260.00

Pertex Light Below Knee Compression Garment WITH grip top (1 pair)

Pertex Light Below Knee Compression Garment WITH grip top (1 pair) - $160.00

Pertex Light Below Knee Compression Garment WITH grip top (2 pairs)

Pertex Light Below Knee Compression Garment WITH grip top (2 pairs) - $320.00

Garment Pair 1 - Pertex Light compression garment options

Size 7 - 15 kept in stock

Pertex Light Sizing

Below knee garment size *

Garment width *

Standard (stock)
Extra wide

Pertex Light Leg Length

Below knee garment leg length *

Short
Regular (stock)
Long

Pertex Light Foot Length

Foot length *

Short
Regular (stock)
Long

Toe *

Open toe (stock)
Closed toe (stock)

Garment colour *

Beige (stock)
Black

Garment Pair 2 - Pertex Light compression garment options

Size 7 - 15 kept in stock

Pertex Light Sizing

Garment Pair 2 - Below knee garment size *

Garment 2 - Garment width *

Standard (stock)
Extra wide

Pertex Light Leg Length

Garment 2 - Below knee garment leg length *

Short
Regular (stock)
Long

Pertex Light Foot Length

Garment 2 - Foot length *

Short
Regular (stock)
Long

Garment 2 - Toe *

Open toe (stock)
Closed toe (stock)

Garment 2 - Garment colour *

Beige (stock)
Black

Comfiwave

Do you need Comfiwave Below Knee compression garment/s? *

Please tick the box to make your selection

Comfiwave Garment Choice

1 x Comfiwave Below Knee Garment (single leg) - $205.00
2 x Comfiwave Below Knee Garment (single leg) - $410.00

Comfiwave compression garment options

Comfiwave Sizing

Comfiwave size *

Small
Medium
Large
Extra Large

All sizes kept in stock

Comfiwave length

Comfiwave length *

Short
Regular
Long

All lengths kept in stock

Easywrap

Do you need Easywrap Foot and Leg Wrap *

Please tick the box to make your selection

Easywrap Choice

1 x Easywrap Light foot and leg (single leg) A pair of A - D liners is included - $270.00
2 x Easywrap Light foot a - $540.00

An order of Easywrap Foot and Leg is supplied with a free pair of a - d liners

Easywrap Foot Sizing

Easywrap Foot Size *

Extra Small
Small
Medium
Large
Extra Large

All sizes and colours kept in stock

Easywrap Foot Sizing

Easywrap Foot Length *

Regular
Long

Easywrap Leg Sizing

Easywrap Leg Size *

Extra Small
Small
Medium
Large
Extra Large

All sizes and colours kept in stock

Easywrap Leg Length

Easywrap Leg Length *

Regular
Tall

Easywrap colour *

Beige (stock)
Black (stock)

Easywrap Liner

Do you need Easywrap Liners? *

Please tick the box to make your selection

Single pair of Easywrap Liners

Single Easywrap A- D Liner - $41.00

2 pairs of Easywrap Linera

2 x Easywrap A- D Liners - $82.00

Easywrap Liner sizing

Easywrap Liner Sizing

Easywrap Liner Size *

XS/S/M
L/XL

Easywrap Liner Colour *

Beige (stock)
Black (stock)

Cica Moisturiser Cream

Single Cica

Single Cica Moisturiser Cream (100ml) stock - $39.60

2 x Cica

2 x Cica Moisturiser Cream (100ml) stock - $79.20

Naqi Body Screen

Single Naqi

Single Naqi Body Screen stock - $41.80

2 x Naqi

2 x Naqi Body Screen stock - $83.60

Steve+ On/Off CombiBox

Steve+ On/Off CombiBox choice

Steve+ On/Off CombiBox (stock) - $198.00

Steve+ On/Off CombiBox Sizing

Steve+ On/Off CombiBox size *

Steve+ easyON

Steve+ easyON choice

Steve+ easyON (stock) - $72.60

Steve
+ EasyOn sizing

Steve+ EasyOn sizes *

Steve+ easyOFF Ring

Steve+ easyOFF Ring choice

Steve+ easyOFF Ring (stock) - $58.30

Steve
+ EasyOff sizing

Steve+ EasyOff sizes *

Steve Glide Open Toe

Steve Glide Open Toe choice

Steve Glide Open Toe (stock) - $36.00

Steve+ Dolphin Glide Open Toe Size *

Small (Foot length less than or equal to 26cm)
Large (Foot length equal to or greater than 26cm)

Gus Grip Mat

Gus Grip Mat choice

Gus Grip Mat (stock) - $23.10

Donning Gloves

Donning Gloves choice

Donning gloves - with latex (stock) - $9.00

Latex Free Donning Gloves choice

Latex Free donning gloves (stock) - $9.00

Donning glove sizes

Donning Gloves Sizing

Choose the size of your donning gloves

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Postage and handling

Price: $18.00

Total

$0.00

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