Liberty Thumb Spica

Name *

Company Name *

North Coast Account #

Title *

Email *

Phone *

1. Does your clinic, office or practice provide insurance billing for DME & Orthotics? *

YesNo

2. Does your clinic, office or practice provide retail sales for DME & Orthotics? *

YesNo

3. If not, does your clinic, office or practice issue/provide supportive orthotics to patients as part of your service model? *

YesNo

4. If no, where does your clinic, office or practice suggest your patients obtain a recommended product like the Liberty Orthotic Thumb Spica? *

AmazonNorth Coast Medical Other

5a. Select sample Liberty™ Thumb Spica orientation *

LeftRight

5b. Select sample Liberty™ Thumb Spica size: *

Small / MediumMedium / Large

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Samples are intended for healthcare professionals only.