Biothotic Order Form

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