American Heelers Orthopedics - Custom Shoe Modification ... · Provide us with information from...
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1-888-443-3537 www.orthopedicshoelift.com [email protected] American Heelers Orthopedics “Heeler Of Broken Soles” 24000 Mercantile Rd. Ste. 14 Cleveland, OH 44122 A. Customer Information: Name ___________________________________________________________ Address (Shipping to) ___________________________________________________________ ___________________________________________________________ City, State, Zip Code ___________________________________________________________ Phone Number ___________________________________________________________ E-Mail Address ___________________________________________________________ (On-line invoice will be sent via email when order is received) B. Check All That Apply: q New Customer q Change of Address q Rush Order: If needed we can express overnight starting at $49.95. q Weight exceeds 200 lbs., 90 Kilos or do you experience compression in material. In this case we may choose to use a harder material to prevent collapse. C. Order Specifications: Shoe Lift Size (Millimeter or Inch) To Be Added To Shoe(s): _____________ (Send only shoe requiring a lift) Check All That Apply: Optional q Honeycomb shoe lift design: Precise carving and drilling of lift building material for up to 50% more flexibility and light weight results for just $19.99. q Golf Shoe, Cleat Shoe, Cycling Shoe, Vibram Five Finger Shoe - $39.99 D. Optional Those who know they need a specific lift size added at the approximate points on the chart below may enter amounts on the diagram below. If left blank we will use our expertise to properly apply the size indicated in Section C with the appropriate taper and balance. E. *Referral Doctor or Company _________________________________________________________ Address _________________________________________________________ Phone Number / Date of birth: _________________________________________________________ PRICING Provide us with information from your orthopedic surgeon, PT, chiropractor or favorite shoe store to receive $5.00 off your order. Free Shipping both ways on orders of two or more shoes. Free shipping on shoe lift modifications over 1 inch. Up to 1/2” or 12 millimeters $68.99 • Up to 3/4” or 19 millimeters $79.98 Up to 1” or 25 millimeters $89.97 • Each additional 1/4” or 6 millimeters $14.99 • Honeycombing $19.99 S/H Cost - $17.95 - OH, GA, MI, RI, MA, VT, TN, WV, NH, KY, IN, NY, ME, PA, NC, IL, DE, VA, CT, SC, MN, MD, WI, NJ S/H Cost - $19.95 - IA, FL, AL, KS, NV, ND, TX, MS, NE, ID, SD, AZ, AR, CO, NM, OK, UT, MT, WY, LA, MO S/H Cost - $22.95 - WA, OR, CA • S/H cost - $24.95 - HI, AK
Transcript of American Heelers Orthopedics - Custom Shoe Modification ... · Provide us with information from...
1-888-443-3537 [email protected]
American Heelers Orthopedics
“Heeler Of Broken Soles”24000 Mercantile Rd. Ste. 14
Cleveland, OH 44122
A. Customer Information: Name ___________________________________________________________ Address (Shipping to) ___________________________________________________________ ___________________________________________________________ City, State, Zip Code ___________________________________________________________ Phone Number ___________________________________________________________ E-Mail Address ___________________________________________________________
(On-line invoice will be sent via email when order is received)B. Check All That Apply: q New Customer q Change of Address q Rush Order: If needed we can express overnight starting at $49.95. q Weight exceeds 200 lbs., 90 Kilos or do you experience compression in material. In this case we may choose to use a harder material to prevent collapse.C. Order Specifications: Shoe Lift Size (Millimeter or Inch) To Be Added To Shoe(s): _____________ (Send only shoe requiring a lift) Check All That Apply: Optional q Honeycomb shoe lift design: Precise carving and drilling of lift building material forupto50%moreflexibilityandlightweightresultsforjust$19.99. q Golf Shoe, Cleat Shoe, Cycling Shoe, Vibram Five Finger Shoe - $39.99D. Optional Thosewhoknowtheyneedaspecificliftsizeaddedattheapproximatepointsonthechartbelowmayenter amounts on the diagram below. If left blank we will use our expertise to properly apply the size indicated in Section C with the appropriate taper and balance.
E. *Referral
Doctor or Company _________________________________________________________Address _________________________________________________________Phone Number / Date of birth: _________________________________________________________
PRICING
Provide us with information from your orthopedic surgeon, PT, chiropractor or favorite shoe store to receive $5.00 off your order.
Free Shipping both ways on orders of two or more shoes. Free shipping on shoe lift modifications over 1 inch.
Up to 1/2” or 12 millimeters $68.99 • Up to 3/4” or 19 millimeters $79.98Up to 1” or 25 millimeters $89.97 • Each additional 1/4” or 6 millimeters $14.99 • Honeycombing $19.99
S/H Cost - $17.95 - OH, GA, MI, RI, MA, VT, TN, WV, NH, KY, IN, NY, ME, PA, NC, IL, DE, VA, CT, SC, MN, MD, WI, NJS/H Cost - $19.95 - IA, FL, AL, KS, NV, ND, TX, MS, NE, ID, SD, AZ, AR, CO, NM, OK, UT, MT, WY, LA, MO
S/H Cost - $22.95 - WA, OR, CA • S/H cost - $24.95 - HI, AK
