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Physicians and Professionals only

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Products

Ankle Systems

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

Sure Step Ankle Brace

Quantity
Brace
Flex
Size
Color

Arizona Ankle Brace

Quantity
Brace
Size

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.