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BCI Compression Garment Request

Complete all measurements in centimeters.

Burn Garment Specialist

Burn Garment Specialist Name — English Only

Patient Information

Patient Name — English Only
Patient Age

Gender
Select... Female Male

Date of Burn Injury

Cause of Burn
Choose cause... Scald / Hot Liquid Flame / Fire Electrical Chemical Contact / Hot Object Other

Is this the patient's first pattern?
Select... Yes No

Compression Garment Needed

Select all garments needed for this patient.

Sleeveless Jacket Pants Sleeve Other:

Please complete the following measurements below

Sleeveless Jacket → Jacket Measurements
Sleeveless Jacket + Sleeve → Jacket + Sleeve Measurements
Sleeve → Sleeve Measurements
Pants → Pants Measurements — stop at desired garment length
Other → Please be specific about what you need

Leave measurements below the desired garment length blank.

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BCI Jacket Measurements

Enter all measurements in centimeters.
Decimals are allowed. Example: 9.5

1. Shoulder to Waist cm	2. Bust cm
3. Axila / Underarm cm	4. Neck cm
5. Back cm	6. Shoulder cm
7. Waist cm

BCI Sleeve Measurements

Enter all measurements in centimeters.
Decimals are allowed. Example: 9.5

Fill out only the measurements needed for the desired sleeve length.

Length Measurements
1. cm	2. cm
3. cm	4. cm
5. cm
Circumference Measurements
A. cm	B. cm
C. cm	D. cm
E. cm	F. cm

BCI Pants Measurements

Enter all measurements in centimeters.
Decimals are allowed. Example: 9.5

For Shorts: Stop measuring at the desired garment length. Leave all measurements below that point blank.

1–11 Measurements

1   cm 2   cm 3   cm 4   cm 5   cm 6   cm 7   cm 8   cm 9   cm 10 cm 11 cm

A–J Measurements

A   cm B   cm C   cm D   cm E   cm F   cm G   cm H   cm I   cm J   cm

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