Wellfeet.com
Order Form:
Please print this form, complete and mail to the address below with a check or money order enclosed.
Name:_____________________________________Street:________________________________
City:______________________________________________State:________
Zip:______________
Phone(with best times to
call)_________________________________________________________
e-mail:__________________________________
Weight: _________Height: ___________Shoe Size:______________
Intended Use: walking/running/cycling/tennis/golf/skiing/other_____________________________
Nature of Problem:_______________________________________________________________
Where did you first hear about us? ____________________________________________________
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Pricing: |
Initial orders |
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Re-orders | ||
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Item |
Price |
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Item |
Price |
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Regular Orthotics |
$275.00 |
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Orthotics- additional pair |
$175.00 |
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Carbon Cycling Orthotics |
$300.00 |
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Carbon Orthotics -additional pair |
$200.00 |
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Shoe Stretcher |
$75.00 |
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New top covers- We install |
$60.00 |
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Total Purchase___________________ |
New top covers- you install |
$35.00 | ||
Please Make Check Payable to: Douglas Ehrenberg, D.P.M. and mail to:
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Well Feet |
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Copyright © 1997 Wellfeet.com. All rights reserved.
Revised: February 04, 2008.