Supplies Request Form

[Pages:1]6299 Guion Rd. Indianapolis, IN 46268

Supplies Request Form

Thank you for partnering with us for your custom and OTC orthotic and bracing needs!

If you are in need of any supplies, please complete the supply request form below and email to clientservice@ or fax to 800-233-2280. You may also leave a voicemail on our DIRECT SUPPLY REQUEST LINE at: 800-444-3632 ext. 146 or you can order supplies online at .

ACCOUNT NUMBER

ACCOUNT NAME

ADDRESS

CITY

STATE

ZIP

PHONE

EMAIL

Use the line next to each item to identify quantity.

ORDER FORMS

SHIPPING MATERIALS

Custom Plus Orthotics (set of 15) ____

USPS Shipping Labels (set of 15) ____

Custom Footlight Economy Orthotics (set of 15) ____

UPS Shipping Labels (set of 15) ____

Custom Richie Brace? (set of 5) ____

Orthotic Shipping Boxes (bundle of 5) ____

Richie Brace? AeroSpring (set of 5) ____

Richie Brace? Shipping Boxes (bundle of 5) ____

OTC Orthotics - SideKicks Mate ____ OTC Orthotics - SideKicks Freestyle ____ OTC Richie Brace? ____ FS6/AF7 Compression Sleeve ____ Foot Gym ____ Orthotic Outgrowth Insurance (set of 5) ____

EDUCATIONAL RESOURCES

Product Catalog Richie Brace? Catalog AFO Medicare Compliance Guide Richie Brace? Tips: Prescription Writing, Modifications, and Troubleshooting

Account Barcode Labels (set of 30) ____



800.444.3632

Richie Brace? Treatment Guide clientservice@

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