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Products

Advantage+ Preforms

Specify the sizes and quanties for each size ordered.
10% discount applies to orders with total quantity of 10 or more.

Sport

Size	Qty




Total Sport	0

Dress

Size	Qty




Total Dress	0

Accommodative

Size	Qty




Total Accommodative	0

Patient Information First Name Last Name Age Weight Female Male Shoe Size Shoe Style

Diagnosis/Condition Treated

Customer Information

Fields marked * are required information.

First Name* Last Name* Practice* License Number
Account No.

If you do not have a PAL account, a representative will contact you to complete your order.

P.O. No. Email*
Office Phone*
Fax

Ship To Company* Address* Suite/Number City* State/Area* Country/Region* Postal Code*

Comments

Shipping and Handling A Shipping & Handling charge will be added to your order total:

Order Total	Charge
Under $50	$3.50
$50–$149.99	$5.50
$150–$299.99	$11.50
$300–$999.99	$16.25
$1,000+	$21.50

Check for C.O.D. Shipping (Adds $8.95)

*Required information

Attention Patients: Any questions or concerns you have about your health or the products described within this Website should be discussed with your healthcare provider.