Commercial Product Requests
Type of request
*
Sales Order (ship and invoice)
Invoice request
Sample/Loaner/Replacement
Product Line
*
ActivAided
eSling
Other
Customer/Account
*
National Orders (Adimo)
Audobon O&P
Bird Medical
Center for Prosthetics & Orthotics
Centura Health Orthotics & Prosthetics
Christine Pfisterer MD
Galion Community Hospital
GIO Medical
Great Wall
HR&G
Jersey Integrative Sports & Spine
Kinex Medical
Legacy Medical Centers
MedEast Post Op & Surgical
Mill Run
Orthopedic Associates
Regeneration Pittsburgh
R&M Rehabilitation
Scheck & Siress Prosthetics & Orthotics
Spectrum Orthopedics
T&E Medical
The Orthopedic Group
UT Southwestern Medical
Westerville DME
Youngstown Orthopaedics
Online Retail Order
Other
Other Customer/Account name
*
Invoice/Contact Email
*
PO#
*
PO#(s) for product being replaced
*
PO# or Invoice# of product sold to trigger restock
Consignment location
*
Adam on hand
Bird Medical
Dr ???
Other/new location
Other/new location:
*
Sample/Demo product condition
*
New
Used/returned product
Will sample be returned?
*
Yes
No
Shipping/Billing address
*
8291 RADCLIFF DRIVE, COLORADO SPRINGS, CO 80920
5410 Powers Center Pt Ste 110C
Colorado Springs, CO 80920
Other
Adam on hand
Shipping/Billing address
*
Other
Audobon O&P
Shipping/Billing address
*
6825 S Galena St, Suite 210, Englewood CO 80112
Other
Bird Medical
Shipping/Billing address
*
411 12th Ave STE 200 Seattle WA 98122
Other
Center for Prosthetics & Orthotics
Shipping/Billing address
*
3030 N Circle Drive STE 110 Colorado Springs CO 80909
Other
Centura Health Orthotics & Prosthetics
Shipping/Billing address
*
870 Palisade Ave STE 205 Teaneck NJ 07666
Other
Christine Pfisterer MD
Shipping/Billing address
*
269 Portland Way South Galion OH 44833
Other
Galion Community Hospital
Shipping/Billing address
*
8291 Radcliff Drive Colorado Springs CO 80920
Attn: Adrien Lopez 69 Altadena Drive Peublo CO 81005
Other
GIO Medical
Shipping/Billing address
*
170 Taylor Station Road Columbus OH 43213
Other
Great Wall
Shipping/Billing address
*
Attn: Lad 1951 Innsbruck Way Salt Lake City UT 84121-1370
Other
HR&G
Shipping/Billing address
*
Attn: Jorge Arrastia 36 Round Hill Road Kinnelon NJ 07405
Other
Jersey Integrative Sports & Spine
Shipping/Billing address
*
Attn: BJ Funke 3181 99th Street Urbandale IA 50322
Other
Kinex Medical
Shipping/Billing address
*
3540 Washington Rd McMurray PA 15317
Other
Legacy Medical Centers
Shipping/Billing address
*
3001 Irwin Road STE E Mt Laurel NJ 08054
Other
MedEast Post Op & Surgical
Shipping/Billing address
*
3777 Trueman Court Hilliard OH 43026
Other
Mill Run
Shipping/Billing address
*
4700 East Hale Parkway Denver CO 80220
Other
Orthopedic Associates
Shipping/Billing address
*
12590 Perry Highway, Wexford, PA 15090
Other
Regeneration Pittsburgh
Shipping/Billing address
*
Attn: Renee Fuller 7205 Woodbury Drive Franklin WI 53132
Attn: Brittany Mauga 14360 W Wilbur Drive New Berlin WI 53151
Other
R&M Rehabilitation
Shipping/Billing address
*
1S376 Summit Avenue Court E Oakbrook Terrace IL 60181
Other
Scheck & Siress Prosthetics & Orthotics
Shipping/Billing address
*
Attn: Casey Phillips 7442 Frank Avenue North Canton OH 44720
Other
Spectrum Orthopedics
Shipping/Billing address
*
Attn: Victor Boland 157 Nottingham Court Aston PA 19014
Other
T&E Medical
Shipping/Billing address
*
Attn: Chris Faith 1145 Bower Hill Road STE 301 Pittsburgh PA 15243
1633 State Route 51 South STE 200 Jefferson Hills PA 15025
Other
The Orthopedic Group
Shipping/Billing address
*
Attn: Patrick Newman 6011 Harry Hines Blvd RM#V2.112 Dallas TX 75390
Other
UT Southwestern Medical
Shipping/Billing address
*
560 North Cleveland Avenue Westerville OH 43082
Other
Westerville DME
Shipping/Billing address
*
6470 Tippecanoe Road Canfield OH 44406
Other
Youngstown Orthopaedics
Other shipping/billing address
Quantity: ActivAided Sport Pullover
AA-TNK-FS
AA-TNK-FM
AA-TNK-FL
AA-TNK-FXL
AA-TNK-MM
AA-TNK-ML
AA-TNK-MXL
AA-TNK-M2X
Quantity: ActivAided Sport Zip
AA-ZIP-FS
AA-ZIP-FM
AA-ZIP-FL
AA-ZIP-FXL
AA-ZIP-MM
AA-ZIP-ML
AA-ZIP-MXL
AA-ZIP-M2X
Quantity:
eSling
520 R s/m
520 R l/xl
520 L s/m
520 L l/xl
519 R s/m
519 R l/xl
519 L s/m
519 L l/xl
517 R s/m
517 R l/xl
517 L s/m
517 L l/xl
Additional notes/ comments
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