Order Form

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? ____________________________________________________

Pricing:	Initial orders		Re-orders
	Item	Price	Item	Price
	Regular Orthotics	$275.00	Orthotics- additional pair	$145.00
	Carbon Cycling Orthotics	$300.00	Carbon Orthotics -additional pair	$170.00
	Shoe Stretcher	$75.00	New top covers- We install	$60.00
	Total Purchase___________________		New top covers- you install	$35.00

Please Make Check Payable to: Douglas Ehrenberg, D.P.M. and mail to:

Well Feet

52 Mohawk Avenue

Corte Madera, CA 94925

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