Compression Garment Prescription Form

Print this form and take it to your physician/NP to sign. The signature and stamp areas are provided below.

Please fill out Name, DOB, and Email — these fields are required.

Compression Garment Prescription

[email protected] • www.lymphclinic.ca

Name*

DOB*

Email*

Diagnosis / Indication

Venous disease (CEAP C3–C6) Varicose veins PTS Post-venous procedure Venous leg ulcer CVI Lymphedema Phlebolymphedema Lipoedema Orthostatic hypotension / POTS Post-operative edema Post-trauma edema Pregnancy-related edema Occupational/prolonged-standing edema Travel VTE risk Hypertrophic burn scar Keloid (post-excision) Other

Recommended Pressure

8–15 15–20 20–30 30–40 40–50

Style

Socks (below‑knee) Stockings (below‑knee) Stockings (thigh‑high) Pantyhose / tights Maternity pantyhose Capri Bermuda Open toe Closed toe Toe cap Sleeve Glove Gauntlet Vest Bra Custom garment Other

Wraps

Foot Calf Knee Thigh Abdominal Binder Compression Bandage Arm Gauntlet

Refills

Pairs

Comments

Physician / NP Signature

Clinic Stamp / Address

Signed Date

Printed Name (optional)

Physician: Please confirm the diagnosis/indication, select the recommended pressure & style, add comments if needed, and sign with CPSO number. Thank you.