DatePatient InformationPatient Name *Patient Email *Patient Phone *Do you have a purchase code?YesNo(optional)What kind of purchase code do you have?Influencer CodeShipping CodeDevice CodeInfluencer CodeThis will be the only chance you have to add an influencer code.Shipping CodeThis will be the only chance you have to add a shipping code.Device CodeThis will be the only chance you have to add a device code.Provider InformationReferring Provider Name *Provider Email(optional)Provider Phone(optional)Referring Provider ZIP *(required)PrescriptionUpload Prescription *Choose FileNo file chosenDelete uploaded file.jpg, .pdf, .png only. MAX 25MBSelect Your Style *I am ordering a cast to block my wrist only - $349I am ordering a cast to block my wrist and thumb - $349I am ordering a cast to block my wrist and fingers (not thumb) - $399I am ordering a cast to cover my hand (my wrist can move) - $249I am ordering a cast to block my elbow (my wrist can move) - $449I am ordering a cast to block my elbow and wrist - $549I am ordering a cast to block my ankle (non-weight bearing) - $449I am ordering a walking boot - $749I am ordering a functional thumb support for my hand - $249Please Select OneImportant Note:The turnaround time on the "Ankle Foot Orthosis - Weight Bearing" orthosis may be longer than other products.Add Strength Coating (comes in white only) *YesNoStrength Coating CostOrthosis CustomizationColor *BlackSilverWhiteYellowOrangeRedPinkGreenLight BlueDark BluePurpleColors in swatches are approximate. Please see image of casts above for more accurate colors.Add-OnsCotton Undersleeve (+$3.00)Order NotesAgree to Terms *I have read and agree to the terms and conditions of the ActivArmor cast & splint order waiver.Shipping InformationName *Email *Street Address *Apt, Ste, etc...City *State *Choose StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZIP *0 / 5Billing InformationHas CouponApprovedInfluencer Calc (Hidden)Billing Info is same as Shipping Info? *YesNoBilling Name *Billing Email *Street Address *Apt, Ste, etc...City *State *Choose StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZIP *0 / 5Orthosis Cost$Add-On Cost$Shipping Cost$Orthosis Discount$Shipping Discount$Influencer Discount$Total Cost$Credit / Debit Card *Submit Order
