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:

SHIPPING INSTRUCTIONS

Ground2-day (additional charges)Overnight (additional charges)Local

Quantity

Quantity:

Foot Shell

Foot Shell 1 Side:

Foot Shell 2 Side:

Foot Shell 3 Side:

Foot Shell 4 Side:

Foot Shell 5 Side:

Foot Shell 1 Size & Color:

Foot Shell 2 Size & Color:

Foot Shell 3 Size & Color:

Foot Shell 4 Size & Color:

Foot Shell 5 Size & Color:

AquaPaw

AquaPaw 1:

AquaPaw 2:

AquaPaw 3:

AquaPaw 4:

AquaPaw 5:

ADDITIONAL COMMENTS

Additional Comments: