[B2B] speedhand Trial Form

speedhand Trial Request

If you are a medical professional 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*

Patient Information

First Name*

Last Name*

Amputation Level*

Transradial

Transhumeral

Amputation Side*

Clinic Information

What is your profession?*

If selected "other," please specify*

What Clinic/Hospital do you work at?*

Address*

City*

Postal Code*

Country*

State*

Province*

Where did you hear about speedhand?*

Please specify

Questions or Comments*

How would you like to be contacted?

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.*

I have read and understand the Terms and Conditions.*