Contact/Order Form

Please submit this order form via e-mail or print out this order form after completing it and mail or fax it to:

Walking Tall
1340 NW 125 Terrace
Sunrise, FL 33323
Phone: 954-646-6918
E-mail: fmaterdo@aol.com

Name:
Mailing address:
City:
State/Province:
Country:
Home Phone:
E-mail:

Please identify and describe yourself:

Activity Level:(light, moderate, athlete)
Please list any foot ailments:

Age:	Sex: Male Female

Upon return of this form with payment, Walking Tall will forward an Impression Packet to you with a postage-paid return envelope. Follow the instructions and return the impression board. The size and type of orthotic you will receive is dependent upon the above questions and structure of your foot. Arch sizes do NOT correspond to the size of your shoe.

Enclose payment of $349.95 plus $20.00 shipping. Payable to Walking Tall. (Price includes fitting, orthotic, and applicable taxes, shipping includes applicable postage and foot print kit.)

Method of Payment

Payment Type:
Cardholder name:
Card number:
Expiration date:

Comments and Questions.