New Account Form

PRACTICE INFORMATION

---

Medical Professional Name *

Title *

Facility Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone Number/Fax Number *

Email Address *

Primary Ordering Contact Name *

Phone Number *

Email Address *

MONTHLY VOLUMES

Average Monthly Orthotics (pairs) *

Diabetic Inserts *

Average Monthly AFOs Prescribed *

ORTHOTIC PREFERENCES

What is the most common type of orthotic you prescribe? *

What shell materials do you prefer in your orthotics? *

What top cover material do you prefer? *

BILLING OPTIONS

Billing Contact Name *

Title *

Phone Number/Fax Number *

Email Address *

Is a purchase order required for payment? *

YesNoBlanket PO

Blanket PO

Do you want your monthly balance charged to a credit card? *

YesNo(if yes, you will be sent an additional "credit card authorization" to complete)

Do you prefer invoices emailed rather than sent with shipment? *

YesNo

(if yes, please list email below)

Will other associates at your facility begin ordering from PAL? *

YesNo

If yes, do you want to bill all associations under the same account? *

YesNo

Mail each associate a separate monthly statement? *

YesNo

SHIPPING INFORMATION

---

Medical Professional Name *

Title *

Facility Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone Number/Fax Number *

Email Address *

Billing Contact Name *

Title *

SUBMIT