Medical Customer Intake
All questions with a red asterisk are required
Customer Name
*
First Name
Last Name
Customer Email
*
example@example.com
Clinic Information
Clinic Name
*
Multiple Locations?
*
Please Select
Yes
No
I don't know
Clinic Address
Enter Suite #, Attention To, or N/A
*
Add a link to company website that lists additional clinic locations
Clinician Info
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Next
Products of Interest
Select all that apply
*
Carbon Fiber AFOs
Carbon Fiber Foot Plates
The Equinus Brace
Ankle Braces
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Next
Accounts Payable Information
Accounts payable address same as shipping address?
Yes
No
Accounts Payable Address
Suite # (if applicable)
Accounts Payable Contact Name
*
First Name
Last Name
Accounts Payable Contact Phone Number
*
Please enter a valid phone number.
Accounts Payable Contact Email
*
example@example.com
Upon receipt of this form, a credit agreement will be sent to the AP contact above. Thank you for your submission!
Submit
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