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 ID:

Activity Level:

Patient Weight:

PO Number
(Optional)

Amputation Side:LeftRight

Amputation Level: BKAK

ADDITIONS

4-Hole Plate

4-Hole Pinlock Mount*

4-Hole Vaccum Mount*

4-Hole Male Pyramid Adapter

4-Hole Female Pyramid Adapter

4-Hole Suction*

4-Hole Lanyard*

"*" = Additional costs/time may apply.

ADDITIONAL COMMENTS

Additional Comments: