Orthopedic Shoe Repair Order Form

     First Name: 
      Last Name: 

Zip/Postal Code: 

 E-Mail Address: 
Payment Method: Check: Money Order

Please select item(s) you wish to order, then print two copies of this form, one to send
to us and other copy for your records. Mail completed order form with payment to:
Shoestring Exchange Shoe Repair
32 Fickett Street
South Portland, ME 04106

Tel: (207) 767-3558
If you have any questions please contact us.

Description Qty Cost
Heel Build-up to 1/2" $15.00
Heel Build-up to 1" $20.00
Full Sole Build-up to 1/2" $25.00
Full Sole Build-up to 1" $35.00
Full Sole Build-up to 2" $50.00
Full Sole Build-up to 3" $75.00
Metatarsal Bars $10.00
Metatarsal Pads $6.00
Heel Pads $6.00
Arch Pads $6.00
Tounge Pads $6.00
Wedges $8.00
Shoe Stretching Width $5.00
Shoe Stretching Length $5.00
Stretching Toes $5.00
Stretching Calf $8.00

Sub Total: $
(5% tax rate) Total Tax: $
Total Order: $
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