PAL Product Pre-Pay Order Form
Please make sure to fill in the required fields and submit this form to complete your order. You will receive an email confirmation upon completion. Please print a copy and include it with your order form and your biofoam box or casts.
ORDERING CONTACT INFORMATION
Account Name
*
PAL Account Number
*
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Contact Number
*
What state are you located in?
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
PATIENT-SPECIFIC INFORMATION
Patient Name
*
First Name
Last Name
Patient Sex
*
Male
Female
Patient DOB
*
-
Month
-
Day
Year
Date
Patient Shoe Size
*
Patient Shoe Width
*
Please Select
Narrow
Medium
Wide
X Wide
XX Wide
XXX Wide
SHIPPING INFORMATION
Are we shipping the order to your office or directly to the patient?
*
Ship to the address on my account
Ship directly to my patient
Ship-to-Patient Address ***If ship to patient, Please select "Ship to Patient" at the bottom of the pricing information which will add $6.50 to your order for shipping***
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
ORDER-SPECIFIC INFORMATION
Is this a new order or an exact duplicate of a previous order?
*
New Order
Exact Duplicate
***OPTIONAL*** New Order Form and Picture Upload (Please still include a copy of your order form with your biofoam box or casts)
Browse Files
Drag and drop files here
Choose a file
Use this to upload a filled-out order form and pictures of anything to note specifically for this order
Cancel
of
Original Order ID
*Enter coupon code EXACTDUP for 10% discount
Original Order Year
Please Select
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
PRICING INFORMATION
Select the product you're requesting from the list below as well as any order options such as Rush, Overnight Ship, and Ship to Patient.
Categories:
All
All
Functional Orthotics
Accommodative Orthotics
AFOs
Order Options
prev
next
( X )
Functional Orthotics
System 3.0 Orthotic
Please fill out a PAL Order Form to enter details for your order
$
140.00
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
ProTech Orthotic
Please fill out a PAL Order Form to enter details for your order
$
112.00
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
Marathotic
Please fill out a PAL Order Form to enter details for your order
$
95.00
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
Advantage +
Please fill out a PAL Order Form to enter details for your order
$
112.00
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
Pedestrian
Please fill out a PAL Order Form to enter details for your order
$
112.00
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
Accommodative Orthotics
Tri-Lam Elite
Please fill out a PAL Order Form to enter details for your order
$
105.00
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
XFit Standard (3 pr)
Please fill out a PAL Order Form to enter details for your order
$
92.00
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
XFit Plus 55 (3 pr)
Please fill out a PAL Order Form to enter details for your order
$
102.00
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
XFit DiaSystems Plus (3 pr)
Please fill out a PAL Order Form to enter details for your order
$
108.00
Quantity
1
2
3
4
5
Item subtotal:
$
0.00
AFOs
Platinum Plastic AFO
Please fill out a PAL Order Form to enter details for your order
$
338.00
Quantity
1
2
Item subtotal:
$
0.00
Platinum Leather AFO
Please fill out a PAL Order Form to enter details for your order
$
398.00
Quantity
1
2
Item subtotal:
$
0.00
Platinum Balance Brace
Please fill out a PAL Order Form to enter details for your order
$
365.00
Quantity
1
2
Item subtotal:
$
0.00
Platinum Profile
Please fill out a PAL Order Form to enter details for your order
$
319.00
Quantity
1
2
Item subtotal:
$
0.00
Order Options
Rush Order
"Rush Order" means that your order will be moved to the front of the line throughout fabrication
$
47.00
Quantity
1
Item subtotal:
$
0.00
Overnight Shipping
Overnight shipping from us back to you
$
50.00
Quantity
1
Item subtotal:
$
0.00
Ship-to-Patient $6.50
Select this if you are wanting us to ship the order directly to your patient
$
Free
Quantity
1
Item subtotal:
$
0.00
Print
SUBMIT ORDER
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