First Name*

Last Name*

Email*

Country*

Address Line 1*

Phone*

Address Line 2

City*

Zip Code*

Are you currently working with a Prosthetist? If yes, please provide their name or clinic name in the section below.*
Yes
No

Name of prosthetist*

Name of prosthetic clinic*

Who is your insurance provider?*

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

Please select the side(s) on which you have limb loss or limb difference:*
Left
Right
Both

Have you ever been fit with a prosthesis?*
Yes
No

Is there anything else you would like to share about your experience as a person living with limb loss that may assist our team with helping to schedule a trial? (optional)

Where did you hear about C-Leg?

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-Leg 4. Your trial request form submission does not guarantee a trial and will be approved. Insurance coverage or an alternate payment method, as well as minimun physical requirements must be considered prior to the approval of a trial.

all fields with (*) are required