Order Form

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)*

Phone (alternate)

Date of Birth (mm/dd/yyyy)

Employer

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

Comments

If your contact, shipping, and order details are correct then click Submit.

Order Information

Patient Information

First Name

Last Name

Email

Primary Phone

Alternate Phone

Address

Street

City

State

Zip

Product Information

Black Pantyhose, # of pairs Beige Pantyhose, # of pairs Almond Paantyhose, # 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

Thank you for your order.

Customer service will review your order, contact you if we need any clarifications, and arrange shipping of your items shortly.