First Name* Last Name*

Email* Phone*

Country* United States Canada Other

Address Line 1*

Address Line 2 City*

State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Zip Code*

Are you currently working with an Orthotist? If yes, please provide their name or clinic name in the comments section* Yes No

Name of orthotist* Name of orthotics clinic*

Please indicate your weight range:* Under 275 lbs 275-300 lbs Above 300 lbs Do not wish to disclose

What is your primary diagnoses?

Affected Side* Left Right Both

Please select the most accurate description of your mobility level* GMFCS Level I GMFCS Level II GMFCS Level III GMFCS Level IV GMFCS Level V

GMFCS Level I: You walk indoors and outdoors and climb stairs without limitation. You perform gross motor skills including running and jumping, but speed, balance, and coordination are impaired.

GMFCS Level II: You walk indoors and outdoors and climb stairs holding onto a railing but experience limitations walking on uneven surfaces and inclines and walking in crowds or confined spaces.

GMFCS Level III: You walk indoors and outdoors on a level surface with an assistive mobility device. Children may climb stairs holding onto a railing. Children may propel a wheelchair manually or are transported when traveling for long distances or outdoors on uneven terrain.

GMFCS Level IV: You may continue to walk for short distances on a walker or rely on wheeled mobility at home and school and in the community.

GMFCS Level V: Physical impairment restricts voluntary control of movement and the ability to maintain antigravity head and trunk postures. All areas of motor function are limited. You have no means of independent mobility and are transported.

Who is your insurance provider?* Commercial Insurance (Employer or Individual Health Plan) Medicare or Medicare Advantage Military (TRICARE,VA,CHAMP-VA) Provincial Health Insurance Self-Pay WarAmps Workers Compensation Other (specify below) If other, please list insurance provider*

Where did you hear about C-Brace? Facebook Twitter Instagram LinkedIn Google Search Bing Referral

I am interested in getting information from Ottobock* By filling out this survey you hereby agree to allow Ottobock to save and use the personal data and medical data, if applicable, that you have provided in the survey form for the purpose of processing/responding to my inquiry. View Ottobock Data Privacy here.*

*We appreciate your interest in the C-Brace. Your trial request form submission does not guarantee a trial will be approved. Insurance coverage or an alternate payment method, as well as minimum physical requirements, must be considered prior to the approval of a trial.

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