Product Issue/Defect Form

Name (person submitting form) *

First

Last

Account # *

Customer/Patient Name with Issue *

Type of Issue/Defect: (select all that apply) *

Name/Model # of Shoe(s) being referenced: *

Date of Purchase: *

Breif Description of Issue/Defect: *

Was follow-up requested by affected customer/patient? *

If Yes, please provide direct contact information (email/phone) for customer:

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