Customer #: _________________________________________________________________ Account Name: __________________________________________________________________________________________

Shipping Address: _______________________________________________________________________________________________________________________________________________________________________

Phone number: ____________________________________________________________Confirm to email: ________________________________________________________________________________________

Pairs of Heat Moldable Inserts 0 1 2 3

(Please Note – If nothing is marked, we will send 3 pairs of Heat Moldable Inserts)

Pairs of Gel Inserts 0 1 2 3 Pairs of Custom Inserts 0 1 2 3 Custom Scan Number

Email orders to: drcomfort.orders@djoglobal.com or Fax orders to: 262-242-9300

To sign up for online ordering, email [email protected] with your Name and Customer number

*This style and/or color is being phased out. Stock may be limited.

ANNIE X Black 4910

AUTUMN Grey 11680

BETTY Black 3810 Chestnut 3820

FLUTE Black Lycra

®

** 2315*

SIZE: 4 4 ½ 5 5 ½ 6 6 ½ 7 7 ½ 8 8 ½ 9 9 ½ 10 10 ½ 11 12 Size 11 ½ not available.

WIDTH: M = A/B W = C/D XW = E/EE

White Crew socks for this patient Mismate Sizes: Left Right

Pairs of Gel Inserts 0 1 2 3 Pairs of Custom Inserts 0 1 2 3 Custom Scan Number

BOSS Black 9510 Chestnut 9520

BRIAN Black 6410

CARTER Black 9110

ENDURANCE Black 6810 White 6840

FRANK Bark 6221 Black 6210

JASON Black 77710 Blue 77750 Red 77770

JUSTIN Chestnut 5520

LIAM Grey 51480

MIKE Multi 8660

Copper 7621R