Order form about of a respiratory vest

please fill out online

Stefan Kühnst
produce of breathing devices
Techno CED
Dorfstraße 53
D-06217 Merseburg - Meuschau Germany
Tel./Fax: +49(0)3461217024

E-Mail: stefankuehnst@hotmail.com
www.kuehnst-chest-exercise-device-iahp.com
Child's Name:

Date of Birth:

Gender: Female: Male:

Date of your next visit in the institut It is very important to give this date!

Phone:

Fax:

E-Mail.:

Date.:




Information to parents
Mother's name Father's name




Shipping-address



postal code
City


Country

Please fill out











+ shipping cost for your country





About the measurements for the breathing vest:

- Please make the measurements following:
- use a measuring tape. Put it circumference of the body of your child
- Please write the numbers into the units of measurements. Don't subtract something!!!
- Your child have to carry wear during the measurements.
- If your child needs pampers, please make the measurements with pampers!!



Beneath Armpits.:


Chest.:


Waist.:


Hip.:




Measure width of chest from armpit to armpit.:

Measure from armpit to waist.:


Measure from waist to hip.:





Measure from beneath armpits to where the legs bends.

Nachricht: