LSO Order Now

LSO 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:

    Lead Time

    Lead Time:

    QUANTITY

    PDAC Approved L-Codes

    Balboa (L0627 & L0642)

    S-XL (25"-45" Waist):

    2XL-4XL (45"-60" Waist):

    Capri (L0631 & L0648)

    S-XL (25"-45" Waist):

    2XL-4XL (45"-60" Waist):

    Avalon (L0637 & L0650)

    S-XL (25"-45" Waist):

    2XL-4XL (45"-60" Waist):

    Infiniti Back Brace (Cash and Carry)

    XS (18"-25" Waist):

    S (26"-32" Waist):

    M (33"-39" Waist):

    L (40"-46" Waist):

    XL (47"-53" Waist):

    XXL (53"-60" Waist):

    ADDITIONAL COMMENTS

    Additional Comments: