Your™ Liner Follow-up Platform

Company*

Prosthetist Name/Surname*

Prosthetist e-mail*

Prosthetist phone number

Reference of the Your™ Liner for which you are placing this request*

Ideally provide the Your™ Liner serial n° (starts with SMT-). Optionally: Patient ID, Order n°.

Clément Gabry (e.g. for France, Belgium, Netherlands, Switzerland FR)Enrico Gibson (e.g. for Germany, Switzerland DE)I don't know

I want to order a duplicate / renewal linerI want to place a warranty claimI want to order a new liner based on a new scan

/! Note /!

To place orders starting from a new scan, you must use the standard ordering platform. Access it with the link hereunder:

=> YOUR™ LINER ORDERING PLATFORM

Initial-fitting is not successful (satisfaction warranty)Liner is prematurely worn out (product warranty)

/! Note /!

Satisfaction warranty claims must be placed within 60 days of the seller's invoice.

Describe why the initial fitting was not successful, and what we should change for the replacement liner:*

Please be as extensive and precise as possible.

Describe the failure mode of the liner.*

Please be as extensive and precise as possible. Ideally, please provide your analysis of why this might have happened.

Upload pictures to substantiate your claim

MotionTech may consider an absence of pictures as a lack of appropriate substantiation. Not uploading any picture thereby puts your warranty claim at risk of being rejected.

NoYes

Describe your modification requests:*

Be as extensive and precise as possible. Examples of modification requests: suction lines heights, textile design, modifications on the 3D model, silicone type, etc.

I requested modifications on the 3D model => I accept the extra feeI am not requesting any modification of the 3D model

Upload pictures / videos to further illustrate the modification you requested

Pictures / videos to illustrate / explain the reason why you ask for some modifications can be very helpful to help us make sure we don't misinterpret your requests. Please upload content to help us understand !

Yes, sure !Sorry, no

Still used currentlyBroken - unusableWorn-out - kept as backup

Grade how satisfied your were with the following aspects of Your™ Liner {referenceOf}

Rows	Not at all satisfied	Rather not satisfied	Neutral	Rather satisfied	Fully satisfied
Fit of the liner
Thickness profile
Workmanship quality
Textile aesthetics
Feel (texture, touch, material)
Lead time (from order to reception)
Service & support from MotionTech

This patient had a liner from another manufacturer before his 1st Your™ LinerThis patient never had a liner before his 1st Your™ Liner

Model name - previous liner from other manufacturer

Please provide as many details as possible allowing us to understand the specific model your patient had

How did Your™ Liner {referenceOf} impact the following aspects compared to when your patient was using his previous {modelName47} liner

Rows	Much worse	A bit worse	Similar	A bit better	Much better	I don't know
Overall satisfaction
Complaints on painful areas of the stump
Overall mobility abilities
Occurence of skin injuries
Occurence of injuries preventing use of the prosthesis until healed
Comfort when wearing the liner
Proprioception
Daily limb volume change
Sweating
Donning & doffing

Feel free to share anything else that's on your mind !

Signature*

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