FootOrthotics™ Order Form

Please fill out this form completely and submit. If you have any questions, please e-mail us. Confirmation will be sent to you via e-mail. The prices on this page are for U.S. deliveries only.

PRODUCT INFORMATION

Premiere FootOrthotics™
$200 (First Pair)

Second Pair Premiere FootOrthotics™
$150 (Second pair must be ordered at the same time)

Level 2 Orthotics
$99.95 per pair


Number you wish to purchase

 


 

 


 

 

Your Age


Years

Your Sex

Male
Female

Your Height


Feet and Inches

Your Weight

Pounds

In which type of shoes will you usually use these orthotics (check all that apply)

Dress Shoes
Ladies Dress Pumps
Athletic or Sport Shoes
Work Shoes / Boots

Please describe intended uses

Referred By

Special Instructions: (Please list specific medical problems or other pertinent information)

PURCHASER INFORMATION

First Name

Last Name

Address 1

Address 2

City

State/Province

ZIP/Postal Code

Country

Phone

Fax

E-mail Address

BILLING INFORMATION

We suggest that you use your credit card so that we can fill your order immediately.  You may mail a check for payment, however we must allow two weeks for the check to clear the bank before your order can be processed.  You may also complete the above, without entering your credit card numbers, then call our office with your credit card information.
Your credit card information will remain confidential.  We guarantee your reimbursement, if your card is used fraudulently by our organization.
Credit card billings will appear in your statement as:
Joshua M. Kaye, D.P.M.

Payment Method
Visa Mastercard

Cardholder Name

Credit Card #

Expiration

MM/YYYY

CVV Code

3-digits on back of card

Zip Code

Zip Code of Credit Card Billing Address

     (Please press only once)


All information on this site © 2011 Joshua Kaye, DPM.