Sample / Sizing Kit Request Form

The requestor agrees to:

Return kits within 30 days of receipt in the same condition as received.
Cover any lost or damaged equipment.
Cover return shipping costs of kits.

Name(Required)

Name of Clinic(Required)

Website

Email(Required)

Phone

Shipping Address(Required)

Sample Device Request(Required)

Please select your kit(s). Due to limited availability, some items may not be available or may ship separately.

Ring Sizing

MCPDriver

ThumbDriver

Single Articulating Tip

PIPDriver (Small)

PIPDriver (Medium)

PIPDriver (Large)

PIPDriver (Static)

GripLock Finger

Patient Identifier(Required)

For sample requests for educational events please contact our CX Team at [email protected] or 888-977-6693.

Date Needed By(Required)

Please allow 3 business days, to include processing and shipping time.

Name

This field is for validation purposes and should be left unchanged.

Please do not submit any personal medical information.

Information is secure: https://www.npdevices.com/privacy-policy/

Are you?(Required)

(Please check the box which most closely applies to you)

Other

Date of Birth

Are you working with a prosthetist?

Yes

No

Name of prostetist/clinic

Insurance?

Yes

No

Insurance provider

Name(Required)

Website

Email(Required)

Phone

Address(Required)

How did you hear about us?

How did you hear about us? Other

Please enter the conference or event name here.

Please enter the webinar name here.

Comments

Phone

This field is for validation purposes and should be left unchanged.

Please do not submit any personal medical information.

Information is secure: https://www.npdevices.com/privacy-policy/