Advanced Care for Lymphedema and Lipedema in Canada

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Compression Garment Prescription Form

Compression Garment Prescription

Please fill out the form completely and accurately.

[email protected] www.lymphclinic.ca

Name

Date of Birth

Email

Diagnosis

Chronic Venous Insufficiency (CVI)

Varicose Veins

Lymphedema

Deep Vein Thrombosis (DVT) Prevention

Post-thrombotic Syndrome (PTS)

Venous Leg Ulcers

Pregnancy-related Edema

Lipedema

Post Mastectomy

Post Cosmetic Surgery

Post-operative Swelling

Diabetic

Other:

Recommended Compression Pressure

8-15 mmHg

15-20 mmHg

20-30 mmHg

30-40 mmHg

40-50 mmHg

Style

Lower Body Styles

Knee High

Thigh High

Pantyhose

Capri

Bermuda

Open Toe

Closed Toe

Upper Body Styles

Sleeve

Bra

Vest

Glove

Gauntlet

Other:

Wrap

Foot

Calf

Knee

Thigh

Abdominal Binder

Compression Bandage

Number of Refills

Number of Pairs

Physician Name

CPSO Number

Date

Physician's Comments