Order form about of a respiratory vest please fill out online

Stefan K�hnst produce of breathing devices Techno CED Dorfstra�e 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 1 breathing vest incl. 1 set of bladders 520,- € 1 set of valves incl. silencers 250,- € 1 air hose with connects to the vest 57,- € 1 set of bladders: 59,- € 2 set of bladders: 95,- €	+ 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.
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