women’s shoes - s3.amazonaws.com · title: om19-mkt00-6483-revi-drc-shoe-order-form_r2.indd...
TRANSCRIPT
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: [email protected] or Fax orders to: 262-242-9300To sign up for online ordering, email [email protected] 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: [email protected] or Fax orders to: 262-242-9300To sign up for online ordering, email [email protected] 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