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					   Acct #:
                                                                                     Tel: 1-888-655-4499 * Fax: 1-866-933-2922
Clinic: (please stamp below)                                                                 www.simsmedicalcorp.com


                                                                                       INSERT ORDER FORM
PO#:

Ordered By:
                                                                                Fax Order to: 1-866-933-2922



         INSERTS
                               Gender   5   -   6   -   7   -   8   -   9   -   10     -   11    -   12   -   13   14   15
       No Minimum
Control Comfort –
                                MEN
   LOW ARCH
Control Comfort –
                           WOMEN
   LOW ARCH
Control Comfort –
                                MEN
   MEDIUM ARCH
Control Comfort –
                           WOMEN
   MEDIUM ARCH
Control Comfort –
                                MEN
   HIGH ARCH
Control Comfort –
                           WOMEN
   HIGH ARCH
Dynamic Comfort Insert          MEN

Dynamic Comfort Insert     WOMEN

Gel Comfort Plus Insert         MEN

Gel Comfort Plus Insert    WOMEN
Heat Moldable Diabetic
                                MEN
Insert
Heat Moldable Diabetic
                           WOMEN
Insert



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posted:10/3/2012
language:Latin
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