ORDER FORM AND PRICE SHEET COMPANY NAME ________ Phone __

							ORDER FORM AND PRICE SHEET
COMPANY NAME __________________________________
Phone ________________________ Fax ____________________ P.O. # __________________________ ORDERED BY __________________________________________

• SH IP TO • ___________________________________
____________________________________________________ Address ____________________________________________________ City State Zip

As Simple As 1. Complete the Order Form 2. Place it in the Impression Box (We Provide) 3. Tape it up, Place our Pre-paid Shipping Label on it. 5. Your Order is Shipped from our Office via Ground Shipping within 5 Working Days.
RIGHT LEFT

Patien t Name _________________________________
Sex __________ Weight __________ Age __________ Check Here If We’re Providing Shoes Shoe Style _____________________ Color __________ Size_________________ Width: M W EW

ADDITIONS Leather Cover Spenco Cover PPT® Full Layer Top Middle Bottom Heel Cushion Metatarsal Pad Metatarsal Bar Toe Crest Pad Horseshoe Relief Pad Heel Spur Pad Depression $3.00 ea. Donut Cutout $3.50 ea. w/ PPT Plug High Medial Flange High Lateral Flange Arch Fill (with same base material) High Heel Cupping Heel Lift Lateral Posting Heel Forefoot Medial Posting Heel Forefoot

CUSTOM MOLDED TOTAL CONTACT DUAL - DENSITY INSERTS Pink and White Plastazote® Pink Plastazote® and Eva ( Recommended for Patients Over 230 Ibs ) 3 Pairs, Same Cast - $85.00 2 Pairs, Same Cast - $65.00 CALL FOR QUOTE ON 1 Pair - $45.00 FUNCTIONAL ORTHOTICS 3 singles (Amputee) - $45.00 **If material and quantity is not selected you will receive 3 pairs Pink and White Plastazote AMPUTATION FILLERS Fillers are incorporated into all sets of inserts unless specified otherwise. R L Hallux and Multi Digit Fillers (up to 4 Digits) - $15.00 ea. R L Transmet and 5 Digit Fillers - $25.00 ea. $3.50 $2.50 $2.50 $3.00 $3.50 $5.00 $4.00 $4.00 $5.00 $3.00 $1.25 $3.50 $2.50 $5.00 $5.00 ea. ea. ea. ea. ea. ea. ea. ea. ea. ea. ea. ea. ea. ea. ea. R R R R R R R R R R R R R R R L L L L L L L L L L L L L L L

INDICATE PROBLEM AREAS ABOVE

527 Pomegranate Avenue • Sebring, FL 33870 • Tel: (877) 524-0639 • Fax: (863) 314-0083 • www.branier.com