FootOrthoticsTM 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. For Canadian and international shipments click here. 

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
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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
Blank
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 ©1998 Joshua Kaye, DPM.