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
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