New Account Form
PRACTICE INFORMATION
Medical Professional Name
*
Title
*
Facility Name
*
Physical Address
*
Unit, Suite, etc.
City
*
State/Province
*
Zip / Postal Code
*
Office Phone
*
Office Email Address
*
Primary Ordering Contact Name
*
Primary Ordering Contact Phone
*
Primary Ordering Contact Email
*
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MONTHLY VOLUMES
Avg. Custom Orthotics (pairs)
*
Please Select
0-1
2-6
7-12
13-18
19-25
26-35
36-45
46-55
56-65
66-75
76-85
86-95
96-105
106+
Avg. Diabetic Inserts (3 pairs each)
*
Please Select
0-1
2-6
7-12
13-18
19-25
26-35
36-45
46-55
56-65
66-75
76-85
86-95
96-105
106+
Avg. Custom AFOs (individual)
*
Please Select
0-1
2-6
7-12
13-18
19-25
26-35
36-45
46-55
56-65
66+
Avg. OTC Orthotics (pairs)
*
Please Select
0-1
2-6
7-12
13-18
19-25
26-35
36-45
46-55
56-65
66-75
76-85
86-95
96-105
106+
CUSTOM ORTHOTIC PREFERENCES
What is the most common type of orthotic you prescribe?
*
Rigid Functional
Semi-Rigid Functional
Flexible Functional
Accommodative
Diabetic Insert
Other
What shell materials do you prefer in your orthotics?
*
Polypropylene
Polyethylene
Composite
Cork
EVA
Other
What top cover materials do you prefer in your orthotics?
*
Imitation Leather
Microfiber
Genuine Leather
Plastazote
EVA
Other
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Billing Options
Billing Contact Name
*
Billing Contact Title
Billing Contact Phone
*
Billing Contact Fax
*
Billing Contact Email (for invoices and statements)
*
Is a purchase order required for payment?
*
Yes
No
Other
ADDITIONAL ORDERING ASSOCIATES
Will other associates at your facility begin ordering from PAL?
*
Yes
No
How do you wish the additional associates to be billed?
Together under the same, main account
Individually under each associate's account
Additional Associate Information - 1
Do you wish to add more Associates?
Yes
No
Additional Associate Information - 2
Do you wish to add more Associates?
Yes
No
Additional Associate Information - 3
Do you wish to add more Associates?
Yes
No
Additional Associate Information - 4
Do you wish to add more Associates?
Yes
No
Additional Associate Information - 5
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SHIPPING INFORMATION
Is the shipping information the same as the billing information?
Yes
No
Medical Professional Name
*
Title
*
Facility Name
*
Physical Address
*
Unit, Suite, etc.
City
*
State/Province
*
Zip / Postal Code
*
Office Phone
*
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ADDITIONAL INFO
Have you been working with anyone from PAL regarding your new account? If yes, please provide their name
Please let us know anything else important here
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