Special Order Form

[av_layout_row border=” min_height=’0′ color=’main_color’ mobile=’av-flex-cells’ id=”] [av_cell_one_fourth] [/av_cell_one_fourth][av_cell_one_half] [av_contact email=’sales@insightful-products.com’ title=’Cast Order Form’ button=’Submit’ on_send=” sent=’Your message has been sent!’ link=’manually,http://’ subject=’Cast Order Form (20% Off)’ autorespond=” captcha=’active’ color=”] [av_contact_field label=’Clinic name’ type=’text’ options=” check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’Clinician’s Name’ type=’text’ options=” check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’Clinic Address’ type=’text’ options=” check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’City’ type=’text’ options=” check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’State / Prov’ type=’text’ options=” check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’Zip / Postal Code’ type=’text’ options=” check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’Phone Number’ type=’text’ options=” check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’Patient Name’ type=’text’ options=” check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’Measurement: Lower Leg circumference (In Inches)’ type=’text’ options=” check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’Item’ type=’select’ options=’Blaze MI (Item #1005), Step-Smart (Item #1006), Classic AI (Item #1002)’ check=’is_empty’ width=”][/av_contact_field] [av_contact_field label=’Option Number (Chrarges apply for additional options)’ type=’text’ options=” check=” width=”][/av_contact_field] [/av_contact] [/av_cell_one_half][av_cell_one_fourth vertical_align=’top’ padding=’30px’ background_color=” src=” background_attachment=’scroll’ background_position=’top left’ background_repeat=’no-repeat’] [/av_cell_one_fourth][/av_layout_row]