IBT

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Evaluation Kit Request

Date Evaluation Kit needed by

Note: arrival by date provided is not guaranteed based on availability of equipment. Next-day air is not available.

PO Number

Name of Requesting Clinician

Clinic Name

Shipping Address

Best Phone Number

Best Email

Billing Contact

Billing Address

Billing Phone Number

Billing Email

Have you been previously trained on Glide via webinar or in-person session?

Yes

No

Purpose of evaluation kit request

Trialing on myself to learn about the system

Trialing on patient to determine candidacy

Trialing on patient to determine number of electrodes needed for order

Other (Fill In)

If trialing on a patient, please provide the following information if you would like the system to be pre-configured:

The hand, wrist, and/or elbow you are considering for the patient

Amputation Side

Right

Left

Amputation Level

Note: the system provided will not be able to connect to a hand, wrist, or elbow. Instead, the control system will be evaluated with a virtual arm. For more information, contact IBT at sales@i-biomed.com or 443-451-7175.

Glide Evaluation Kits loaner time period is 2 weeks, after which a daily late fee of $100 will be charged. Please contact IBT at sales@i-biomed.com or 443-451-7175 if you need to extend the loaner period.

Signature

Additional Notes / Comments

Lernen Sie Glide kennen