Print this form and fax to: Fitter by the Foot    dba NewWay to Health, LLC. at (704) 397-8520

Shoe Style______________________________

Shoe Size_______________________________                   (For women, order one size smaller your normal shoe)

Shoe Color______________________________

Quantity_________________________________

Price Each__________  Price Total___________                              CLOGS $67.95      SANDALS $47.95

Total____________________________________

Name_____________________________                                      Ship to____________________________

Address___________________________                                                ____________________________

City____________________ State____________ Zip___________

Phone_____________________

Email______________________________

Fax_______________________

                      Method of payment:

______Visa    _____MasterCard    ____AMEX   ____ Check

Card #________________________________ Last 3 numbers on back of card_________

Expiration Date__________

Name on card _______________________ 

Address & Zip code of card holder______________________________________

Fitter by the Foot   dba NewWay to Health, LLC
133 Squeaky Tree Lane
Statesville, NC 28625        1-704-546-3061 phone   704-397-8520 fax