Niagra Foot Order Form

GENERAL

Clinic Name:

Prosthetist Name:

Facility:

Billing Address:

City:

State:

Zip Code:

Shipping Address

Please Check the box if Shipping Address is same as billing Address.

Billing Address:

City:

State:

Zip Code:

Phone Number:

Email:

PATIENT

Patient ID:

Activity Level:

Patient Weight:

PO Number
(Optional)

Amputation Side:LeftRight

Amputation Level: BKAK

Color: