POL Exchange/Return Form Clinic InformationClinic Name* Practitioner Name* First Last Email* Phone*Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Patient InformationPatient Name First Last AgeWeight (in lbs)Shoe SizeGenderMaleFemaleIs this a Shoe Return or Shoe Exchange?*Shoe ReturnShoe ExchangeNote: Footwear being returned for credit or exchange must be in original condition, otherwise extra charges will apply. Shoe only’s cannot be returned for credit.EXCHANGE #1Shoe Type*Men'sWomen'sYouthWith Orthotic? Yes From:Make Model Size Width To:Make Model Size Width Additional InstructionsExchanging another? Yes EXCHANGE #2Shoe Type*Men'sWomen'sYouthWith Orthotic? Yes From:Make Model Size Width To:Make Model Size Width Additional InstructionsAdd another? Yes EXCHANGE #3Shoe Type*Men'sWomen'sYouthWith Orthotic? Yes From:Make Model Size Width To:Make Model Size Width Additional InstructionsCommentsThis field is for validation purposes and should be left unchanged. Δ
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