Niagara Foot Order Form

Niagara Foot Order Form

GENERAL

Clinic/Hospital Name:

Provider Name:

Shipping Address:

City:

State:

Zip Code:

Phone Number:

PO#:(optional)

Email:

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

Billing Address:

City:

State:

Zip Code:

PATIENT

Patient Name:

Patient Age:

Patient Weight:

Gender: MaleFemale

Activity Level:

Amputation Side:LeftRight

Amputation Level: BKAK

ADDITIONS

Left Foot Shell - Light Color*

Right Foot Shell - Light Color*

Left Foot Shell - Dark Color*

Right Foot Shell - Dark Color*

"*" = Additional costs/time may apply.

ADDITIONAL COMMENTS

Additional Comments: