American Heelers Orthopedics - Custom Shoe Modification ... · Provide us with information from...

1-888-443-3537 www.orthopedicshoelift.cominfo@orthopedicshoelift.com

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