BIOTHOTIC ORDER FORM
ORDER INFORMATION :
Company Name : ______________________________________________________________________________________
Account #: ___________________________________________ PO #: __________________________________________
Contact Name : ________________________________________________________________________________________
Phone : ___________________________________ Email : ____________________________________________________
TO ORDER :
Web orthofeet . shoes Email orders @ orthofeet . com Phone 800.524.2845 Fax 201.767.6748
Ship-To Name : ______________________________________________________________________________________
Ship-To Address : ____________________________________________________________________________________
City : ___________________________________________ State : _________________ Zip : __________________________
PROFUNCTION
SPORT
MEN WOMEN MEN WOMEN
Code Qty . Code Qty . Code Qty . Code Qty . 5FW 5SW 6FW 6SW
7FM |
7FW |
7SM |
7SW |
8FM |
8FW |
8SM |
8SW |
9FM |
9FW |
9SM |
9SW |
10FM |
10FW |
10SM |
10SW |
11FM |
11FW |
11SM |
11SW |
12FM 13FM 14FM
12SM 13SM 14SM
For men ’ s dress and women ’ s casual shoes . 3 / 32 ” thick at the forefoot .
For shoes with removable inserts or extra room . 3 / 16 ” thick at the forefoot .
* Please note : All Biothotic Orthotics have a shelf life of one year *
Email orders @ orthofeet . com | Phone 800.524.2845 | Fax 201.767.6748 335 Chestnut Street , Norwood , NJ 07648