Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Shipping Address (where you want your socks to be mailed) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Have you worn compression products before?

Yes

No

Please check off any of the following conditions that apply to you:

Diabetes (personally)

Diabetes (family history)

Arterial Disease

Congestive Heart Failure

Phlebitis

Numbness/Tingling In Feet

Skin Conditions

Leg/Foot/Ankle Surgery

Tired/Achy Legs

Varicose Veins (personally)

Varicose Veins (family history)

Current treatment of Deep Vein Thrombosis (blood clot in the leg)

Currently Pregnant

Within Six Weeks Post-Partum

Privacy Policy *

I have read and agree with KL Health's Privacy Policy (found at klhealth.com/privacy)

I agree

*

I confirm that the information I have provided is accurate and clear. Any changes after this point may result in processing delays and additional costs.