Luna Medical, Inc. | Demo Request Form

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Demo Request Form

Demo Request Form

If you would like to receive demos of any of the products we have available, fill out and submit the form below. We will forward the information you provide to the manufacturer of the garments specified. Please note that different manufacturers have different demo policies and you may be contacted by a representative of the manufacturer regarding the demo you requested.

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* Clinician Name:
* Facility Name:
* Facility Address:
* City:
* State:	* Zip Code:
* Phone:
Email:
Comments:
DAYTIME, ELASTIC SUPPORT JUZO - Arm Sleeve - Varin Soft-In with Silicone Border JUZO - Arm Sleeve - Helastic Cotton JUZO - Hand Glove - Helastic JUZO - Hand Gauntlet - Helastic JUZO - Leg Stocking - Varin Soft Full Knit with Silicone Border JUZO - Leg Stocking - Varin Soft Sewn to Body Part JOBST - Arm Sleeve - Elvarex JOBST - Hand Glove - Elvarex JOBST - Leg Stocking - Elvarex MEDI - Hand Glove - Medi 95 DAYTIME, NON-ELASTIC SUPPORT CIRCAID - Leg Garment - Ready-Fit 2000 (see note below regarding CircAid garments) NIGHTTIME, NON-ELASTIC SUPPORT CIRCAID - Arm Sleeve - Measure-Up 2001 (see note below regarding CircAid garments) CIRCAID - Leg Garment - Graduate (see note below regarding CircAid garments) REIDSLEEVE - Arm Garment - Classic REIDSLEEVE - Arm Garment - ContourPlus with PowerSleeve REIDSLEEVE - Arm Garment - OptiFlow RM REIDSLEEVE - Leg Garment - Contour with PowerSleeve JOVI - Arm Garment - Jovi with Jovi Jacket NOTE ON CIRCAID GARMENTS: All CircAid garments require you to request a certification test and complete it before demo garments are supplied. CircAid will contact you regarding this after you submit a request for one of their garments. TERMS AND CONDITIONS OF DEMO REQUEST By choosing "Accept Terms and Submit Request", the clinician agrees and understands that the garment(s) requested on this form remain the sole property of the manufacturer. These demonstration units are NOT FOR SALE and are NOT TO BE USED FOR CLINICAL TRIAL PURPOSES. It is further understood that upon request from the manufacturer, one or all of these units will be returned. It is understood that the effectiveness of the garment can be greatly reduced if the garment is not custom made to the particular patient's measurements. No manufacturer recommends nor endorses sleeve sharing for hygienic reasons as well as the risk of infection commonly associated with lymphedema patients. Should the requester of the demonstration garment(s) have patients try a garment on, it is recommended only to do so with a sterile cotton stockinette underneath.

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Luna Medical, Inc. 49 E Elm St., Chicago, IL 60611 | | 1-800-380-4339 | 1-888-696-0299 (fax)