You may submit this form on-line, or print it out for fax/mail orders.

Personal Information:

Name
E-Mail
Address
City State Zip
Home Telephone Work Telephone

Please answer the following questions:
(all information is kept confidential)

Shoe Size Shoe Width
Age Weight (pounds) Sex Male Female
Occupation
Are you diabetic? Yes No
Hours per day spent on your feet
Activity Level: Light Moderate Active
Do you participate in sports? Yes No
If yes, which sports
Please describe your foot complaints:

How many pairs of FOOT MATES supports are you ordering?
Check here if paying by check or money order (mail-in only):
Credit Card Information: Visa Master Card Discover
Card Number: Exp. Date:

If ordering by mail, please include your signature below:

When we receive this form with payment, we will forward you a foot impression kit with simple to follow illustrated instructions. Return the impression kit in the postage paid return envelope. We will then handcraft your FOOT MATES foot supports form your foot impressions and other information we receive with your order. Due to the custom craftsmanship required to create the FOOT MATES support, please allow 3-4 weeks for delivery of your final product. If you do not receive confirmation of your order after one week, please call 1-800-561-3668(FOOT) or in Atlanta call (770) 448-1848.