Custom Sandal and Clog Program 2016 United States: 2905 Veterans Memorial Highway, Suite #2, Ronkonkoma, NY, 11779 T: 800-645-5520 | F: 800-419-0772 Canada: 160 Markland Street, Markham, Ontario, Canada, L6C-OC6 T: 877-644-4344 | F: 866-538-9472 Please: Serial # _________________________________________________ • Submit one form for each pair ordered. Opened By ____________ Incoming Postage _____________________ • Call ahead with any special instructions. Date Received ____________________________________________ • Avoid processing delays by providing ALL requested information. LAB USE ONLY • Order carefully. Additions and accommodations requested after Patient Information the initial order is placed will incur a fee. Patient’s First Name __________________________________________ Practitioner/Clinic Information Patient’s Last Name ___________________________________________ Account # _______________________ P.O. _______________________ Street Address _______________________________________________ Account Name _______________________________________________ City/St/Zip/Postal Code _________________________________________ Practitioner Name ____________________________________________ Telephone ( ) __________________ Date of Birth (M/D/Y) ___________ Phone __________________________ Fax _______________________ Diagnosis or Chief Complaint ____________________________________ Email _____________________________________________________ (not intended for severely compensated feet) Street Address _______________________________________________ City/St/Prov _________________________________________________ REQUIRED INFORMATION Zip/Postal Code ______________________________________________ Sex M F Height _________ Weight __________ Recast from previous order Return cast to clinician Shoe Size________ WIDTH (very important) ___________________ Serial # ____________________________________________________ Weight bearing tracing enclosed Custom copy authorization Charge to: MasterCard VISA Amex Discover This is a prepaid order # _________________________________________________________ Check enclosed Check # _______________________ Expiration Date _______________ Signature _______________________ Money order enclosed Check # _______________________ ADDITIONS AND MODIFICATIONS Naot® Right Left Women’s Aster Women’s Melody Heel Cushion Black Matte Leather Buffalo Leather Metallic Road Leather Stardust Leather Met Pad Vintage Gray Leather Gold Shimmer Leather Silver Thread Leather Pressure Disbursement Pad Women’s Anika Women’s Mikaela Brushed Black Leather Shiraz Leather Crazy Horse Leather Full Sole Varus Wedge Silver Threads Leather Biscuit Leather Full Sole Valgus Wedge Women’s Jive Beige Snake Leather Shiny Black Leather Heel Spur Pad Women’s Rome Men’s Jeff Heel Raise Black Matte Leather Buffalo Leather Oily Brown Nubuck 1/8” 3/16” 1/4” Rumba Leather Polar sea Leather Toe Crest Men’s Fiord Women’s Karaoke Black Leather Crazy Horse Leather Special Topcover White Leather Metal Leather Neoprene Plastazote® PPT® Black Leather Stardust Leather Men’s Lappland (Standard 1/8”) Black Matte Leather Buffalo Leather Women’s Sound Vintage Gray Leather Comments/Special Instructions Gold Grecian Leather Men’s Mikael ____________________________________ Black Madras Leather Crazy Horse Leather Vintage Gray Leather ____________________________________ Women’s Karenna ____________________________________ Black Crinkle Leather Buffalo Leather ____________________________________ White Leather Black Luser leather ____________________________________ Stardust Leather Black Matte Leather ____________________________________ Luggage Brown Leather ____________________________________ ____________________________________ ____________________________________.