FREE SAMPLE REQUEST (NEW CUSTOMERS ONLY)

First name

Last name

Practice Name

DME Buyer (manager/lead doctor)

Buyers Email

Phone

Address

Address Line 2

City

State

Zip

Ankle Braces (pick max of 2)

Boot Walkers (pick max of 1)

Night Splints (pick max of 2)

Post Op Shoes (pick max of 1)

Square Toe

Round Toe

Nitrile Gloves (pick max of 1)

Small

Medium

Large

XLarge

If selecting Boot Walkers, note low or high top sample

Aspen-Summit 10, 15 or 20 Watt Lasers