Submit by Email
604 N. Parkway Street
P.O. Box 125
Wayland, IA 52654
Tel 877-766-7384
Fax 319-256-2501
www.mdorthopaedics.com
Name of Company/Parent’s Name: ___________________________________________
Description
Qty
AFO Pair (L1930 x 2)
 Gray  Pink  Blue
AFO Toe Stilt Pair (L1930 x 2 & L3380 x 2)
AFO/PFS Pair (L1971 x 2)
Billing Address: __________________________________________________________
AFO/PFS Toe Stilt Pair (L1971 x 2 & L3380 x 2)
City: _______________________ State: _____ Zipcode: _______ Country: __________
Ponseti™ Bar (L3150 & L2768)
Shipping Address (if different): ______________________________________________
______________________________________________
_______________________________________________
Phone: (
) __________________ Email : ___________________________________
Patient’s Name: _____________________________ Patient’s Date of Birth: _________
Physician’s Name: _____________________ Orthotist’s Name: ____________________
Left (cm)
Right (cm)
Dobbs Bar (L2300 or L3150 & L2210 x 2)
Pressure Saddles, each (L3649)
AFO Socks, 3 pack
Dorsi Ramp
My Clever Night-Night Shoes by Karen Moss
Stock Orders
Size
A
Print Form
Qty
The Parents' Guide to Clubfoot by Betsy Miller + sales tax
Shipping Options
B
 Ground $7  3 Day Select $10  2nd Day Air $12  Next Day Air $25
 Next Day Air Early AM $50  International - Call for a Quote
 Saturday Delivery (air packages only), additional $16
C
D
E
Method of Payment:
F
 VISA
Shoulder Width
 Amex
 Discover
 PO # ________________
CC # ________________________ Exp Date ______ Name ______________________
All bars are pre-packaged at 60º abduction and 10º dorsiflexion; please specify if other settings are required.
Left Abduction
 Master Card
Right Abduction
Right Dorsiflexion
Left Dorsiflexion
A
B
D
E
C
Length and width measurement locations
(5% discount for cc payment when paid in full at time of order)
F
Circumference measurement locations
Special Instructions: ____________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
All orders received by 10 AM CST Mon-Thurs will ship same day as long as items
are available; any order received after 10 AM will ship the following business day;
MD Orthopaedics is closed on Fridays.
Date Ordered
Need By Date
Ordered By
Document # FRM 7.2-1-3, Revision 0