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 (primary)*

Date of Birth*

Height

Weight

Primary Insurance Company

Insurance ID #

Primary Care Physician (PCP)

PCP Street Address

PCP City

PCP State

PCP Zip Code

PCP Phone

Measurements (from Chart)

Picture 1 (inches)

Picture 2 (inches)

Picture 3 (inches)

Picture 4 (inches)

Picture 5 (inches)

Product Information

Black Pantyhose, # of pairs

Beige Pantyhose, # of pairs

Almond Pantyhose, # of pairs

Black Thigh High, # of pairs

Beige Thigh High, # of pairs

Almond Thigh High, # of pairs

Black Knee High, # of pairs

Navy Knee High, # of pairs

Tan Knee High, # of pairs

Anti-Spam

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