Customer Sample Request
All questions with a red asterisk are required
Customer Name
*
First Name
Last Name
Customer Email
*
example@example.com
Shipping Information
Clinic Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Enter Suite #, Attention To, or N/A
*
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Products of interest
Select all that apply
*
F3 Anterior AFO Sample
F3 Anterior FlexTrim AFO Sample
F3 Anterior Pediatric AFO Sample
F5 Posterior Lateral AFO Sample
F5 Posterior Lateral FlexTrim AFO Sample
F5 Posterior Medial AFO Sample
UFO-51 Universal AFO Sample
Magnetic Strap Sample
Magnetic Strap w/ Loop Sample
T-Strap Sample
The Equinus Brace Sample
X-Glide Rigid Flat Carbon Foot Plate Sample
X-Glide Flexible Flat Carbon Foot Plate Sample
X-Glide Rigid Morton's Extension Carbon Fiber Foot Plate Sample
X-Glide Flexible Morton's Extension Carbon Fiber Foot Plate Sample
X-Glide Contoured Rigid Carbon Fiber Foot Plate Sample
X-Glide Contoured Flexible Carbon Fiber Foot Plate Sample
X-Glide Pediatric Rigid Flat Carbon Fiber Foot Plate Sample
X-Glide Pediatric Flexible Flat Carbon Fiber Foot Plate Sample
Mach8 Ankle (Figure 8) Ankle Brace Sample
Jetlace (Speedlace) Ankle Brace Sample
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How many carbon fiber AFOs do you currently use per month?
Please Select
0
1-10
11-24
25-49
50+
What brands and products do you utilize currently?
What is your current price for carbon fiber AFOs?
How many night splints do you currently use per month?
Please Select
0
1-10
11-24
25-49
50+
How many carbon fiber foot plates do you currently use per month?
Please Select
0
1-10
11-24
25-49
50+
What is your current price for carbon fiber foot plates?
How many ankle do you currently use per month?
Please Select
0
1-10
11-24
25-49
50+
What brands and products do you utilize currently?
What is your current price for ankle braces?
Please provide any special instructions or notes:
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