women’s shoes - s3.amazonaws.com · title: om19-mkt00-6483-revi-drc-shoe-order-form_r2.indd...

Customer #: _____________________________________________ Account Name: _____________________________________________________________

Shipping Address: ____________________________________________________________________________________________________________________

Phone number: __________________________________________ Confirm to (email/fax): _______________________________________________________

Pairs of Heat Moldable Inserts _____ 0 _____ 1 _____ 2 _____ 3 (Please Note - If none filled out, we will send 3 Heat Moldables)

Pairs of Gel Inserts _____ 0 _____ 1 _____ 2 _____ 3 Pairs of Custom Inserts _____ 0 _____ 1 _____ 2 _____ 3

Email orders to: drcomfort.orders@djoglobal.com or Fax orders to: 262-242-9300To sign up for online ordering, email web@drcomfort.com with your Name and Customer number

+Available in Narrow width sizes 8-11, M/W width 4-11, 12 or XW width 4-11*Not available in sizes 4-5, 10.5, 12**Not available in sizes 4-5***Not available in size 12XW(DD) - Double Depth Width M=C/D, W=E/EE, XW=3E/4E

CUSTOMER INFO

INSERTS

SHOE TYPE

WOMEN’S SHOES

Patient Name (Please Print) _____________________________________PO# (If Applicable) ________________________

Date: ______________________ Ordered By: _________________________________________________________________

SIZE:

___ 4

___ 4 1/2

___ 5

___ 5 1/2

___ 6

___ 6 1/2

___ 7

___ 7 1/2

___ 8**

___ 8 1/2**

___ 9**

___ 9 1/2**

___ 10**

___ 10 1/2**

___ 11***

___ 12

Size 11 1/2 not available

WIDTH:

___ N = A/AA+

___ M = A/B

___ W = C/D

___ XW = E/EE

____ ANNIE ACORN 4520*

____ ANNIE BEIGE 4530*

____ ANNIE BLACK 4510*

____ ANNIE BLUE 4550*

____ ANNIE X (DD) BLACK 4910*

____ ANNIE X (DD) BEIGE 4930*

____ BETTY BLACK 3810+

____ BETTY CHESTNUT 3820+

____ BREEZE BLACK 0810+

____ BREEZE COFFEE 0820+

____ BREEZE LT GOLD 0830+

____ CARA BLACK 38010***

____ CARA BROWN 38020***

____ COLLETTE BEIGE 0030*

____ COLLETTE BLACK 0010*

____ COLLETTE WHITE 0040*

____ DIANE RED 10670***

____ DIANE BLACK 10610***

____ DIANE GREY 10680***

____ FLUTE BLK LYCRA 2315+

____ GRACE BLACK 10310***

____ GRACE WHITE 10340***

____ GRACE SEAFOAM GREEN 10325***

____ KATY GRN/TURQ 37725*

____ KATY PINK 37770*

____ KATY PURPLE 37755*

____ KATY TURQUOISE 37750*

____ LUCIE X (DD) BLACK 2610***

____ LU LU BLACK 4610+

____ LU LU CHESTNUT 4620+

____ MAGGY BEIGE 4030*

____ MAGGY BLACK 4010*

____ MAGGY CHESTNUT 4020*

____ MAGGY X (DD) BLACK 4110*

____ MALLORY BLACK 10210***

____ MALLORY BROWN 10220***

____ MARLA (DD) BLACK 0910*

____ MEGHAN PURPLE 37855*

____ MEGHAN TURQUOISE 37850*

____ MERRY JANE BEIGE 4430*

____ MERRY JANE BLACK 4410*

____ MERRY JANE LYCRA 4415*

____ PARADISE BLACK 2110+

____ PARADISE BURGUNDY 2170+

____ PARADISE PEWTER 2105+

____ PARADISE SADDLE TAN 2120+

____ PATTY BEIGE 1030*

____ PATTY BLACK 1010*

____ PATTY WHITE 1040*

____ REFRESH BERRY 3976***

____ REFRESH BLACK 3910***

____ REFRESH BLUE 3950***

____ REFRESH LIME GREEN 3925***

____ REFRESH X (DD) BLUE 2950***

____ RILEY BLACK 0210*

____ RILEY MIDNIGHT 0250*

____ RILEY WHITE 0240*

____ RUTH NUDE 10530***

____ RUTH GREY 10580***

____ RUTH BLACK 10510***

____ SPIRIT BLACK 3210***

____ SPIRIT WHITE 3240***

____ SPIRIT X (DD) BLACK 2410***

____ SPIRIT X (DD) WHITE 2440***

____ VICTORY PINK 3470***

____ VICTORY WHITE 3440***

____ VIGOR BLACK 2510+

____ VIGOR CHESTNUT 2520+

MEN’S SHOES

Patient Name (Please Print) _____________________________________PO# (If Applicable) ________________________

Date: ______________________ Ordered By: _________________________________________________________________

Pairs of Heat Moldable Inserts _____ 0 _____ 1 _____ 2 _____ 3 (Please Note - If none filled out, we will send 3 Heat Moldables)

Pairs of Gel Inserts _____ 0 _____ 1 _____ 2 _____ 3 Pairs of Custom Inserts _____ 0 _____ 1 _____ 2 _____ 3

Email orders to: drcomfort.orders@djoglobal.com or Fax orders to: 262-242-9300To sign up for online ordering, email web@drcomfort.com with your Name and Customer number

MKT00-6483 Rev J

+These styles available in sizes 12.5 and 13.5**Only available in sizes 7.5-12, 13 and 14(DD) - Double Depth Width M=E/EE, W=3E/4E, XW=5E/6E

____ BOSS BLACK 9510

____ BOSS CHESTNUT 9520

____ BRIAN ACORN 6520

____ BRIAN BLACK 6410+

____ BRIAN X (DD) ACORN 6920

____ BRIAN X (DD) BLACK 6910

____ CARTER (DD) BLACK 9110**

____ CHRIS BLACK 77810 **

____ CHRIS GREY 77880 **

____ CLASSIC BLACK 8410

____ CLASSIC CHESTNUT 8420

____ DOUGLAS BLACK 6610

____ DOUGLAS CHESTNUT 6620

____ EDWARD X (DD) BLACK 9610

____ ENDURANCE BLACK 6810

____ ENDURANCE WHITE 6840

____ ENDURANCE PLUS BLACK 7310

____ FISHERMAN BLACK 9810

____ FISHERMAN CHESTNUT 9820

____ FRANK BARK 6221

____ FRANK BLACK 6210

____ GORDON BLACK 10110

____ GORDON WHITE 10140

____ GORDON BLUE 10150

____ JACK BLUE 51050

____ JACK BLACK 51010

____ JACK GREY 51080

____ JASON BLACK 77710 **

____ JASON BLUE 77750 **

____ JASON RED 77770 **

____ JOHN BROWN 51120

____ JOHN BLACK 51110

____ JUSTIN BLACK 5510

____ JUSTIN CHESTNUT 5520

____ MIKE MULTI 8660

____ PATRICK BLACK 8510

____ PATRICK CHESTNUT 8520

____ PATRICK MULTI 8560

____ PERFORMANCE BLACK 7611

____ PERFORMANCE BLK/GRY 7610

____ PERFORMANCE BLUE 7650

____ PERFORMANCE RED 7670

____ PERFORMANCE X (DD) BLK/GRY 9910

____ PROTECTOR BLACK 9310

____ RANGER BLACK 9410

____ RANGER CHESTNUT 9420

____ ROGER BROWN 10420

____ ROGER BLACK 10410

____ ROGER MIDNIGHT 10411

____ RUK BLACK 7910**

____ RUK BROWN 7920**

____ SCOTT BLACK 9210+

____ SCOTT CHESTNUT 9020

____ SCOTT KHAKI 9030

____ STALLION BLACK 8710+

____ STALLION CHESTNUT 8020

____ WILLIAM BLACK 6310+

____ WILLIAM CHESTNUT 6020

____ WILLIAM X (DD) BLACK 6110

____ WING BLACK 8310

____ WING CHESTNUT 8320

____ WINNER BLACK 5710

____ WINNER WHITE 6740

____ WINNER PLUS BLACK 7210

____ WINNER PLUS WHITE 7240

____ WINNER X (DD) BLACK 7710

____ WINNER X (DD) WHITE 7740

SIZE:

___ 6

___ 6 1/2

___ 7

___ 7 1/2

___ 8

___ 8 1/2

___ 9

___ 9 1/2

___ 10

___ 10 1/2

___ 11

___ 11 1/2

___ 12

___ 12 1/2+

___ 13

___ 13 1/2+

___ 14

___ 15

WIDTH:

___ M = B/C/D

___ W = E/EE

___ XW = EEE/EEEE

Customer #: _____________________________________________ Account Name: _____________________________________________________________

Shipping Address: ____________________________________________________________________________________________________________________

Phone number: __________________________________________ Confirm to (email/fax): _______________________________________________________

CUSTOMER INFO

SHOE TYPE

INSERTS