Product Order Form - American Foot Care - Podiatrists and Foot Surgeons - Podiatry - Foot and Ankle Surgery - Wart removal - Ingrown toenail trimming

Ordering Information

To place an order please fill out the form below. Once completed you can submit it by:

Phone - (212) 877-3062

Fax - (212) 873-9521

Online Order Form

240 West End Avenue
(Corner of 71st Street)
New York, NY 10023

(212) 877-3062
(212) 873-9521 - Fax
info@americanfootcare.com

Customer Information

Your Name

Street Address

Address 2 (Suite or PO Box)

City

State Zip Code

Phone 1

Fax

E-Mail Address

Order Information

Products:	Ace Bandage $ 3.00	Sal Plant Gel $ 12.00
	Ambulatory Shoe $ 125.00	Seal-tight $ 20.00
	Ankle Brace $ 4.00	Silopad Met $ 30.00
	Band Aid $ 11.00	Sof Gell Heel Cup $ 12.00
	Biofreze $ 10.00	Sprain Pack $ 24.00
	Breeze Mist $ 10.00	StJ Half Soleution $ 30.00
	Coflex $ 3.00	STJ Full Soleution $ 38.00
	Corn Pad $ 5.00	Soleution Modified $ 50.00
	D Sole $ 50.00	Surgical Shoe $ 20.00
	Dolgit Cream $ 18.00	Cam Walker $ 115.00
	Gauze Pads $ 12.00	Closed Surgical Shoe $ 25.00
	Gentamicine $ 5.00	Telfa Pads $ 6.00
	Inner Sole $ 12.00	Tube Foam $5.00
	Kerasal $ 13.00	Ureacin 10 Lotion $ 15.00
	Lazer Lotion $ 18.00	Wart Pack $ 23.00
	Metatarsal Pad $ 6.00	Silopos Products
	Foam Metpad $ 4.00	Gel Corn Pad $ 7.00
	Micro Pore Tape $ 2.50	Gel Toe/Finger Cap $ 6.00
	Mole Skin Pads $ 6.00	Gel Air Insoles $ 15.00
	Nail Pack $ 23.00	Heel Cups $ 15.00
	Pediboro Soaks 28 Pack $ 8.00	IBU Top Cream $ 25.00
	Provodine Solution $ 6.00	Toe / Finger Tubes $7.00
	Restore Nail Med $ 20.00	Toe Separator $ 6.00
		Toe Spreader $ 6.00

Other: (List other products)

Shipping & Handling (See Chart)		Shipping Rates Order less than $ 150 - Shipping = $5.00 Order more than $ 150 - Shipping = Free Handling Rates Order less than $ 50 - Handling = $5.00 Order more than $ 50 - Handling = Free
Order Total:

Payment Terms:	Sending Check (Payable to Dr. Antonetz - US dollars)
	Credit Card
Credit Card Type:	Visa MasterCard Discover American Express
Card Number:		Exp. Date:

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