SafeStep - General Order Form

General Order Form

Ph. 866.712.STEP (7837)
Fx. 208.728.0091
34 Naugatuck Avenue
Milford, CT 06460
www.safestep.net
info@safestep.net
9/9/2010

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Simply complete and fax to 208.728.0091 or enter orders on website. SafeStep will match any distributors price on Aircast, DJO, Aetrex, OrthoFeet, Pedors and PowerStep. SafeStep features free electronic billing and compliance documentation when orders are entered online. Expect a fax order confirmation to review for completeness and accuracy.

Name of person placing order: _______________

Coupon Code: _______________

Item #	Description/Patient Name	Gender	Quantity	Color	Size	Width
QuickStart	100 PressureStats, TempStat, Step-Board, Neuro testing tools
PS101	PressureStat, box of 100
TS101	TempStat, box of 6

Call for information about SafeStep's free inventory management system.

Photocopy as needed