[B2C] MPK Trial Form

If you are interested in receiving more information, please fill out the form below. Your local Ottobock representative will reach out to you directly.

Contact Information

First Name*

Last Name*

Email*

Phone*

Country*

State

Province

City*

Postal Code*

Our Microprocessor Knees are intended for above-knee amputations. Please use our Clinic Locator to find a Certified Prosthetist near you to provide you with the best solutions for your indication.

Please indicate your weight range:

Under 275 lbs

275-300 lbs

Above 300 lbs

Do not wish to disclose

Please select the product you are interested in trying*

Have you ever been fit with a prosthesis?

Yes

Which product have you been fit with? (check all that apply)

Microprocessor-Controlled Knee

Mechanical Knee

Do you have a history of falling?

Yes

Do you regularly use an assistive device while wearing your prosthesis?

Yes

Clinic Information

Are you currently working with a clinician?*

Yes

Clinic Name

Clinician Name

Insurance Provider*

If other, please list insurance provider

Where did you hear about this Ottobock product?

If you selected "other," please specify

I would like to get more information about events, products, and services from Ottobock and confirm that the above information is correct.

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.*