Product Codes:
24-086 Small
-- Quantity:
24-087 Medium
-- Quantity:
24-088 Large
-- Quantity:
Accessories:
Replacement Liner
(Washable)
Shipping Preference: Ground 2-Day P.M. 2-Day A.M. Next Day P.M. Next Day A.M.
(If no preference is indicated, this order will be shipped 2 Day P.M.) Note: We do not ship new or repaired products directly to patients.
Ordered by:
Phone # (
)
Patient’s Name:
BILLING: P.O. Number
Townsend Account #
Bill To:
Address:
City:
State:
Zip Code:
Country:
Phone: (
)
Fax: (
)
Ship To:
Address:
City:
State:
Zip Code:
Country:
Phone: (
)
Fax: (
)
Townsend Design
4615 Shepard St., Bakersfield, CA, 93313
Phone: 800.432.3466 or 661.837.1795; Fax: 800.798.2722
Please complete and fax this form to 800.798.2722 (24-hours a
day). If you are calling in your order, this form indicates the options
and information that will be required by our staff. For phone orders,
please call 800.700.2722 between 6:00 a.m. and 4:00 p.m. (PST).
Night
Splint
Rehabilitative
Solutions
Adult Sizing Reference
Small:
Men’s Shoe Size Up To 7; Women’s Shoe Size Up To 7.5
Medium:
Men’s Shoe Size 7.5-10; Women’s Shoe Size 8-10.5
Large:
Men’s Shoe Size 11.5 Up; Women’s Shoe Size 10.5 Up
