Hanger Clinic Free Information Request Form

What are you looking for today? *
Please Note: Hanger Clinic is committed to the health and safety or our patients and employees during the COVID-19 crisis, and we are currently unable to mail printed information packets. Instead, you will receive digital information via email.
Which bracing and support solution(s) are you interested in?
Please note: The WalkAide is an advanced Functional Electrical Stimulation (FES) System for the treatment of Foot Drop caused by upper motor neuron injury. If you are looking for information on general walking aides, please uncheeck the option for WalkAide and select the appropriate category from the list above (i.e. diabetic shoes, AFO, stance control support, or general lower limb bracing).
Please note: ExoSym is available exclusively at Hanger Clinic in Gig Harbor, Washington (near Seattle). Are you are able to travel for treatment?

* Hanger Clinic is unable to assist with travel expenses for treatment *
Please select which level of LIMB LOSS SOLUTIONS you are interested in? *
Please select which specific category of UPPER LIMB LOSS SOLUTIONS you would like information on: *
Please select all Limb Loss Solutions that you would like information on:
Please select which specific category of LOWER LIMB LOSS SOLUTIONS you would like information on: *
Please select the best description of your limb loss or limb difference: *
 +
 +

Thank you for the clarification. Please complete the information below and you will receive an email shortly with additional information on ExoSym, candidacy requirements, and an application to determine eligibility.  This email will also contain the direct contact information for our ExoSym team, in case you have additional questions.

Thank you for the clarification. While the ExoSym is available exclusively at our Gig Harbor location, we do have other bracing options available at Hanger Clinic locations nationwide. Please complete the information below to receive an email with information on lower limb orthotic alternatives, as well as the ExoSym.
 
If you are ready to schedule a free consultation at your local Hanger Clinic to discuss alternative options, contact your local Hanger Clinic. 
How did you hear about Hanger Clinic? *
Are you the patient or a representative other than the patient? *
Are you the patient or a representative other than the patient? *
Are you the patient or a representative other than the patient? *
Are you the patient or a representative other than the patient? *
Are you the patient or a representative other than the patient? *

Please provide your contact information below:

Please provide the patient's contact information below:

In order to provide information, we need to collect contact information. Any contact information you provide will not be provided to any third party companies and will only be used exclusively by Hanger Clinic to assist you in your needs.
Please let us know what type of patient : *
 +
Would you be interested in scheduling a free evaluation at a nearby clinic? *
Please note: if you have requested a specific location that does not provide the service you are inquiring about, we will forward your information and request(s) to the nearest clinic that can assist you. 
Please note: if you have requested a specific location that does not provide the service you are inquiring about, we will forward your information and request(s) to the nearest clinic that can assist you. 
Do you have a current prescription? *
Please note: A prescription is required in order to file for insurance coverage. While you may have a free consultation with your local Hanger Clinic without a prescription, we are unable to make specific recommendations, create cost estimates, or order products without a prescription from your medical doctor.  
Please click the button below to finalize your request
Secured by Formsite