Order Form

Efficient fulfilment of your compression stocking needs through your insurance. We do the paperwork, so you don't have to.

Complete and submit this form to initiate your order. Asterisks " * " indicate required fields.

Information

General Information

First Name*

Last Name*

Email*

Street Address*

City*

State*

Zip Code*

Phone*

Date of Birth*

Primary Insurance Company

Insurance ID #

Primary Care Physician (PCP)

PCP Street Address

PCP City

PCP State

PCP Zip Code

PCP Phone

Measurements in inches (from Chart)

Height*

Weight*

Ankle Circumference*

Calf Circumference*

Calf Length

Thigh Circumference

Thigh Length

Order Details - Enter # of pairs

Black Pantyhose

Beige Pantyhose

Black Thigh High

Black Thigh High Open Toe

Beige Thigh High

Beige Thigh High Open Toe

Black Knee High

Black Knee High Open Toe

Beige Knee High

Beige Knee High Open Toe

Anti-Spam

Comments