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DATE: 01/27/2022
Are you an existing dealer?*
- Yes, I already have an account
- No, I am a new dealer and want to open an account
Section Break
P.O.NO:
Shipping Method*
- Ground (5-7 business days)
Order Details
1- iWALK3.0 Hands Free Crutch (Case Pack - 6 units)
Price: $645.00 Quantity:
Item# HFC30303
2- Trifold Brochures - 25 brochures per pack. Specify quantity of packs. Limit 5 per order. See image below:
Price: $0.00
Item# SPA50400-25
Quantity
3- iWALK RX Pad - used by physician's offices and clinics - 25 sheets per pad - limit 5 per order - see image below:
Price: $0.00
Item# POP53506
Quantity
Total Before Tax and Shipping:
$0.00
CAD
Ordered by:*
First Name Last Name
Email (order confirmation will be sent to this address)*
Enter Email Confirm Email
Phone*
Are you a VGM member? (VGM is a DME / HME GPO)
- Yes
- No
Please provide your VGM membership number. Note - VGM discounts will not appear on this order form but will be applied to your order before processing.
Billing Information
Company Info
Company Name
Address*
Street Address Address Line 2 City Province Postal Code
Credit card information*
- I will provide my credit card information now
- Please have someone contact me for credit card information
Cardholder name (exactly as printed on the card)*
Credit card number*
Expiration date (mm/yy)
CVV2 code*
Street address of card holder*
Postal code of card holder*
Name of person to contact*
Phone*
Best time to call*
Shipping Information
- Shipping Info Same As Billing
Company Info
Company Name
Address*
Street Address Address Line 2 City Province Postal Code
Comments
Would you like an iWALKFree representative to provide you with your Online Ordering System user name and password?*
- Yes
- No
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Thank you for your business!

iWALKFree, Inc. 130 North Marina Drive, Long Beach, CA 90803 PH :562-653-4222
E: sales@iwalk-free.com

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