Please fill-up completely the compression stockings Intake form. Also, for the measurements, please see the image below for reference. <div id="panel-55989-1-0-0" class="so-panel widget widget_vfb_widget vfb_widget_class panel-first-child panel-last-child" data-index="1" > Compression Stockings Intake FormOrder Date *Your Name *Your Phone Number *Your Email Address *Date of Birth *Insurance Company *Insurance Policy Number *Insurance Certificate or ID *Prescription (Doctor’s note) required *YesNo MeasurementsAnkleLeft (in) Right (in) Calf ( * Thickest area of your calf )Left (in) Right (in) Calf Length (in) HeightYour height in inches (It helps determine the proper lengths of stockings) Health HistoryIs there Edema or Discoloration? *YesNoAny surgical or venous treatments scheduled? *YesNoDo you have any arterial insufficiencies? *YesNoAre you pregnant? *YesNoHave you had a DVT *YesNoAre you diabetic? *YesNo VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: </div>