Required Contact Information. Name. Phone Number (____) _____-______. Address Line 1. Address Line 2. City. State ___. Z
Shoe Service Q&A Form Required Contact Information
Optional Contact Information
Name ___________________________
Customer Since __________________
Phone Number (____) _____-_________ 12460 SW Broadway St. Beaverton, OR 97005 503.643.1266
Address Line 1 ____________________
Birthday Club
Address Line 2 ____________________
City ___________________
State ___
Day ____ Month ___________
Email ___________________________
Zip ________
Describe What’s Being Fixed? Men’s Shoes
Women’s Shoes
Men’s Boots
Women’s Boots
Orthopedic Shoe/Insert modification to foot doctor Rx presecription
More Information
Color ______________________
Single Item
What Do You Want Done? Soles
Heels
Full Half Guards (protective half sole)
High Heel Tips
Just Toe Section
Regular Heels
Re-attach
Re-attach
Shine
Stretch
Waterproof Cleaning ________________________ Orthopedics and Lifts Shoe Length
Height - (How much to add)
Removable?
Other details - (Rx-Prescription)
Width
Length
Arch
Shaft
What Do You Want Done? Please mark on these shoes the areas you’d like us to address, and share any information you’d like us to know below: _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________
What Do You Want Done? Please mark on these shoes the areas you’d like us to address, and share any information you’d like us to know below: _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________
