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

$175.00

 

Carbon Cycling Orthotics

$300.00

 

Carbon Orthotics -additional  pair

$200.00

 

 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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Copyright 1997 Wellfeet.com. All rights reserved.
Revised: February 04, 2008.