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Fabric Colors: Velcro Colors:
Thumb splints: Order# Price
Premie...(Up to 6 months)..............................1601................$8.95
Sm. Infant (6 mo- 18 mo)...............................1612................$8.95
Infant (18 mo- 3 yr)........................................1602................$8.95
Child (3 yrs to 10 yrs)....................................1603................
$9.95
Teen (10 yrs to 16 yrs)........................ ..........1604.................$11.95
Adult (16 yrs - up) .........................................1605.................$11.95
[Choose 2 fabric colors]
[Choose 1 velcro color]
ITEM
ORDER # SIZE
Left/Right
COLOR
Quantity
Thumb Wrist Velcro
Splint
1601
premie L
2
6 HP
3
Splint
1603
child
R
13 13
G
1
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[Choose 2 fabric colors]
[Choose 1 velcro color]
ITEM
ORDER # SIZE
Left/Right COLOR
Quantity
Thumb Wrist Velcro
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Comments:
Name:
Name:
Address:
Address:
Phone #: Contact Name:
Purchase Order #