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: