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LSO Order Form

GENERAL

Clinic/Hospital Name:

Provider Name:

Shipping Address:

City:

State:

Zip Code:

Phone Number:

Billing Point of Contact:

Billing Contact Email:

PO#:(optional)

Email:

Please check the box if billing address is same as shipping address.

Billing Address:

City:

State:

Zip Code:

Lead Time

Lead Time:

QUANTITY

PDAC Approved L-Codes

Balboa (L0627 & L0642)

S-XL (25"-45" Waist):

2XL-4XL (45"-60" Waist):

Capri (L0631 & L0648)

S-XL (25"-45" Waist):

2XL-4XL (45"-60" Waist):

Avalon (L0637 & L0650)

S-XL (25"-45" Waist):

2XL-4XL (45"-60" Waist):

Infiniti Back Brace (Cash and Carry)

XS (18"-25" Waist):

S (26"-32" Waist):

M (33"-39" Waist):

L (40"-46" Waist):

XL (47"-53" Waist):

XXL (53"-60" Waist):

ADDITIONAL COMMENTS

Additional Comments: