Niagara Foot Order Form Niagara Foot 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: Quantity Quantity: 1234More - Specify in Comments Foot Shell Foot Shell Side:NoneLeftRight Foot Shell Size & Color: None27cm Caucasian27cm Dark26cm Caucasian26cm Dark25cm Caucasian25cm Dark24cm Caucasian24cm Dark AquaPaw AquaPaw:NoneBlueBlack ADDITIONAL COMMENTS Additional Comments:
