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PRACTICE INFORMATION
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
Is a purchase order required for payment?
Yes
No
Blanket PO
Blanket PO
Do you want your monthly balance charged to a credit card?
Yes
No
(if yes, you will be sent an additional "credit card authorization" to complete)
Do you prefer invoices emailed rather than sent with shipment?
Yes
No
(if yes, please list email below)
Will other associates at your facility begin ordering from PAL?
Yes
No
If yes, do you want to bill all associations under the same account?
Yes
No
Mail each associate a separate monthly statement?
Yes
No
SHIPPING INFORMATION
Medical Professional Name
Title
Facility Name
Street Address
City
State/Province
ZIP / Postal Code
Phone Number/Fax Number
Email Address
Billing Contact Name
Title
SUBMIT