PAL 2nd 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 for your records
ORDERING CONTACT INFORMATION
Account Name
*
PAL Account Number
*
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Contact Number
*
PATIENT-SPECIFIC INFORMATION
Patient Name
*
First Name
Last Name
Patient Sex
*
Male
Female
Patient DOB
*
-
Month
-
Day
Year
Date
ORIGINAL ORDER INFORMATION
Original Order ID (Optional)
Original Order Year (Optional)
Please Select
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Original Product Type
Please Select
System 3.0
ProTech
Marathotic
Steppin' Out
TL Product
Advantage
Pedestrian
TriLam Elite
XFit Standard
XFit Plus 55
XFit DiaSystem Plus
Platinum Plastic AFO
Platinum Leather AFO
Platinum Balance AFO
Platinum Profile AFO
Patient Shoe Size
Please Select
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
10.5
11
11.5
12
12.5
13
13.5
14
14.5
15
15.5
16
16.5
17
17.5
18
How Many Pairs?
Please Select
1
2
3
2ND ORDER DETAILS
Please note that a 10% 2nd order discount applies only when it is an exact duplicate of the original order. Any changes will remove the 10% discount from your invoice
Is the 2nd order an EXACT duplicate of the original order?
Yes
No (A new order form will be required)
New Product Type
Please Select
System 3.0
ProTech
Marathotic
Steppin' Out
TL Product
Advantage
Pedestrian
TriLam Elite
XFit Standard
XFit Plus 55
XFit DiaSystem Plus
Platinum Plastic AFO
Platinum Leather AFO
Platinum Balance AFO
Platinum Profile AFO
Please list any changes here
If there are any changes to the original order, please upload a new order form and any applicable pictures here
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Order Processing & Shipping
*
Standard Processing
Rush Processing (add'l. $47)
Overnight Shipping (add'l. $50)
Ship-to-Patient (add'l $6.50)
Ship-to-Patient Address
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
Print
Save
SUBMIT ORDER
Should be Empty: