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Compression Garment Prescription Form
Compression Garment Prescription Form
Pressure Garment Prescription
Patient Information
Patient Name:
Date of Birth (DD/MM/YYYY):
Address:
Phone Number:
Health Card Number:
Prescribing Practitioner Information
Practitioner Name:
Clinic/Facility Name:
Address:
Phone Number:
License/Registration Number:
Pressure Recommendation (Compression Class)
Class 1 (Light Compression): 15-20 mmHg
Mild edema, tired achy legs, minor varicose veins, DVT prevention (travel), minor swelling during pregnancy.
Class 2 (Moderate Compression): 20-30 mmHg
Moderate lymphedema, moderate to severe varicose veins, post-sclerotherapy, post-surgical, moderate edema, active ulcers.
Class 3 (Firm Compression): 30-40 mmHg
Severe lymphedema, severe CVI, chronic edema, healed ulcers, post-thrombotic syndrome.
Class 4 (Very Firm Compression): 40-50+ mmHg
Severe lymphedema, severe chronic venous insufficiency, elephantiasis. (Typically custom-made or specialized cases)
Indications for Compression Therapy
Lymphedema: Primary / Secondary (specify affected limb/area:
Chronic Venous Insufficiency (CVI)
Varicose Veins
Deep Vein Thrombosis (DVT) Prevention
Post-Thrombotic Syndrome
Post-Surgical Edema/Swelling (specify surgery/area:
Edema/Swelling due to other causes (specify:
Ulcer Management/Healing
Orthostatic Hypotension
Travel/Long Periods of Sitting/Standing
Other (specify):
Compression Garment Details
Type of Garment:
Compression Socks
Stocking
Arm Sleeve
Gauntlet/Glove
Other (specify):
Length/Style:
Knee-High (AD)
Thigh-High (AG)
Pantyhose (AT)
Arm (CG)
Hand (CH)
Other (specify):
Foot Style (for leg garments):
Open Toe
Closed Toe
Other (specify):
Color (if specified):
Quantity (pairs/units):
Side (for unilateral garments):
Left
Right
Bilateral
Specific Instructions for Patient/Fitter
Donning/Doffing Aids:
Wear Schedule:
Care Instructions:
Follow-up/Re-measurement Schedule:
Other Notes:
Prescriber Signature (Type Name):
Date of Prescription (DD/MM/YYYY):
Download Prescription (PDF)
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Compression Garment Prescription Form
Compression Garment Prescription Form
Pressure Garment Prescription
Patient Information
Patient Name:
Date of Birth (DD/MM/YYYY):
Address:
Phone Number:
Health Card Number:
Prescribing Practitioner Information
Practitioner Name:
Clinic/Facility Name:
Address:
Phone Number:
License/Registration Number:
Pressure Recommendation (Compression Class)
Class 1 (Light Compression): 15-20 mmHg
Mild edema, tired achy legs, minor varicose veins, DVT prevention (travel), minor swelling during pregnancy.
Class 2 (Moderate Compression): 20-30 mmHg
Moderate lymphedema, moderate to severe varicose veins, post-sclerotherapy, post-surgical, moderate edema, active ulcers.
Class 3 (Firm Compression): 30-40 mmHg
Severe lymphedema, severe CVI, chronic edema, healed ulcers, post-thrombotic syndrome.
Class 4 (Very Firm Compression): 40-50+ mmHg
Severe lymphedema, severe chronic venous insufficiency, elephantiasis. (Typically custom-made or specialized cases)
Indications for Compression Therapy
Lymphedema: Primary / Secondary (specify affected limb/area:
Chronic Venous Insufficiency (CVI)
Varicose Veins
Deep Vein Thrombosis (DVT) Prevention
Post-Thrombotic Syndrome
Post-Surgical Edema/Swelling (specify surgery/area:
Edema/Swelling due to other causes (specify:
Ulcer Management/Healing
Orthostatic Hypotension
Travel/Long Periods of Sitting/Standing
Other (specify):
Compression Garment Details
Type of Garment:
Compression Socks
Stocking
Arm Sleeve
Gauntlet/Glove
Other (specify):
Length/Style:
Knee-High (AD)
Thigh-High (AG)
Pantyhose (AT)
Arm (CG)
Hand (CH)
Other (specify):
Foot Style (for leg garments):
Open Toe
Closed Toe
Other (specify):
Color (if specified):
Quantity (pairs/units):
Side (for unilateral garments):
Left
Right
Bilateral
Specific Instructions for Patient/Fitter
Donning/Doffing Aids:
Wear Schedule:
Care Instructions:
Follow-up/Re-measurement Schedule:
Other Notes:
Prescriber Signature (Type Name):
Date of Prescription (DD/MM/YYYY):
Download Prescription (PDF)
Generating PDF... Please wait.
