P017

5Rev

A

Quote

Credit Card Info

Customer Name Customer No. Purchase Order No. Fax

juxtafit™ premium

circa

id®

inel

astic

com

pres

sion

garm

ents

Boot Only

graduate™

classicflex™

Left QuantityLower Extremity

Notes:

power added compression band™ (default)

juxtafit™ premium ankle foot wrap

juxtafit™ premium interlocking ankle foot wrap

single band ankle foot wrap™

Standard foot options

graduate foot optionboot attached (default)boot separate

Foot Options Cover up color

black (default)

beige

juxtafit™ premium ankle foot wrapattached separate

Made-to-measure foot option

Foam liner color options:Interior: beige (default) red turquoise

Exterior: black (default) beige red turquoise

QuantityRight

no boot