Kirkland Foot Orthotics Order Form

Date
First Name
Last Name
Address
City, State, Zip
Email Address
Home Phone
Second Phone
Height
Weight
Orthotic Size		B C D E F
Orthotic Model		Three-quarter length composite — $79.95 Full Length EVA Speri — 79.95 Full Length Poron — $89.95 Dressette® — $79.95
Price		$ WA residents please add 8.8% sales tax.
Shipping		$ $8.00 for one or two orthotic pairs. $15.00 for three or four othotic pairs. Add an $8.00 for each increment of two pairs ordered.
Total Order Amount		$