Order Form

Are you a *

Repeat Patient
New Patient

Referred By: *

How will you be using your custom orthotics? *

Everyday & Work
Sports Activities

What's your sport? (Click on one image to make your selection) *

(Click on one image to make your selection)

What's your day like? (Click on one image to make your selection) *

On My Feet All Day
Normal Everyday Activity

(Click on one image to make your selection)

My Pain *

No Pain (Preventative used)
Diagnosis
Lower Extremity

Diagnosis *

General Pain *

Please let us know if pain issue is on the Left, Right, or Both side. *

Left Side
Right Side
Left and Right Side

Additional Info

Shoe Size *

Male
Female
Kids

Male Shoe size *

Female Shoe Size *

Junior Kids Shoe Kize *

Shoe Orthotic Fit

Full Length
3/4 Length

Patient Information

Name *

First

Last

Email *

Shipping Address Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Delivery Method *

Ship
Pick Up

Enter Discount Code

Quantity: PLEASE SELECT 1, 2 OR 3 PAIRS (click only on one selection per order) *

1 Pair $195.00** - $ 205.00
2 Pairs $380.00** ($10.00 Discount) - $ 400.00
3 Pairs $555.00** ($30.00 Discount) - $ 585.00

**Regular Price per pair $195.00 plus a $10.00 shipping fee.

Total Amount**

$ 0.00

**A $10.00 shipping fee per pair was added to your total.

Quantity: PLEASE SELECT 1, 2 OR 3 PAIRS (click only on one selection per order) *

1 Pair $195.00** ($20.00 Discount Applied) - $ 175.00
2 Pairs $390.00** ($40.00 Discount Applied) - $ 350.00
3 Pairs $585.00 ** ($60.00 Discount) Applied - $ 525.00

**No additional shipping fee per pair will be added to your total.

Total Amount

$ 0.00

Patient Information

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