PAL 2nd Order Form

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 NameLast Name
E-mail*
example@example.com
Contact Number*
PATIENT-SPECIFIC INFORMATION
Patient Name*

First NameLast Name
Patient Sex*

MaleFemale
Patient DOB*

MonthDayYear
Date
ORIGINAL ORDER INFORMATION
Original Order ID (Optional)
Original Order Year (Optional)
Original Product Type
Patient Shoe Size
How Many Pairs?
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?

YesNo (A new order form will be required)
New Product Type
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

Cancelof
Order Processing & Shipping*

Standard ProcessingRush 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

CityState

Zip Code
Should be Empty:

ORDERING CONTACT INFORMATION