New Account Form

PRACTICE INFORMATION

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Medical Professional Name *

Title

Facility Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone Number/Fax Number *

Email Address *

Primary Ordering Contact Name

Phone Number

Email Address *

MONTHLY VOLUMES

Average Monthly Orthotics (pairs)

Diabetic Inserts

Average Monthly AFOs Prescribed

ORTHOTIC PREFERENCES

What is the most common type of orthotic you prescribe?

What shell materials do you prefer in your orthotics?

What top cover material do you prefer?

BILLING OPTIONS

Billing Contact Name

Title

Phone Number/Fax Number

Email Address for Invoices and Statements

Is a purchase order required for payment?

YesNoBlanket PO

Blanket PO

Do you want your monthly balance charged to a credit card?

YesNo(if yes, you will be sent an additional "credit card authorization" to complete)

Will other associates at your facility begin ordering from PAL?

YesNo

If yes, do you want to bill all associations under the same account?

YesNo

Mail each associate a separate monthly statement?

YesNo

SHIPPING INFORMATION

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Medical Professional Name

Title

Facility Name

Street Address

City

State/Province

ZIP / Postal Code

Phone Number/Fax Number

Email Address for Invoices and Statements

Billing Contact Name

Title

SUBMIT