OrthoFoam High-Force PIP Extension Orthotic Sample Request

Name *

Title *

Company Name *

Emal *

Phone *

North Coast Account #

Who is your preferred distributor? *

North Coast MedicalPerformance HealthMedlineOther

How often do you see patients with PIP stiffness or boutonnière deformity who could find relief by using the OrthoFoam High-Force? *

Every dayWeeklyOccasionallyRarely

Have you have used other products similar to OrthoFoam High-Force? *

Deroyal LMBPerformance Health Spring Finger Extension SplintOrthoFoam PIP Extension OrthoticNo, I have not used similar products

Other Distributor

Share with us your thoughts on the pricing for the OrthoFoam High-Force ($28.95): *

Too expensiveJust about rightToo inexpensive

What sample size would you like to receive? *

XSSMLXL

Mailing Address

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