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ORDER FORM
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Customer Name
*
Address
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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New Hampshire
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Tennessee
Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Use Primary Ship-To Address On File
Use Primary Ship-To Address On File
Phone
*
Layout
Patient Name
PO# (If Applicable)
Layout (copy)
Date
Ordered By
MANUFACTURE
Dr. Comfort
Apex
Anodyne
Layout
SHOE TYPE
ITEM NUMBER
COLOR
Layout
SIZE
WIDTH
N = A/AA
M = A/B
W = C/D
XW = E/EE
INSERTS: Pairs of Heat Moldable Inserts:
*
0
1
2
3
*** Please Note / If none filled out, we will send 3 Heat Moldable Inserts***
Pairs of Gel Inserts:
0
1
2
3
Pairs of Custom Inserts:
0
1
2
3
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