Nabtesco Loaner Request

Name*

Enter your name

Company*

Street address*

City*

State (Abbrev)*

Zip Code*

Phone number*

Email*

Verify Email*

Other Information

Any additional information

Which of these best describes you?*

Select all that apply

I am the practitioner who fit this knee

I did not provide this knee, but am taking over this patients care

I have been trained on the fitting/programming

I have not received training on this knee

Reason for Loaner Request*

Serial Number (if sending knee for maintenance)

Requested Trial Start Date

Only needed for trial request not maintenance request

Month/Day/Year

Requested Trial End Date

Only needed for trial request not maintenance request

Month/Day/Year

Nabtesco Loaner Agreement

Loaner units are provided for free for a 2-3 week Patient Trial Period.
A Loaner Fee of $1,000 per week may apply for each week beyond the Trial Period.
No modification, disassembly and reverse-engineering of the Loaner unit is permitted.
Repair costs for damaged Loaner units will be charged back to practice.
Outbound shipping costs will be paid by Nabtesco & return shipping costs will be paid by the practice requesting the Sales Demo Unit.
In the event that the Loaner unit is lost or not returned, an invoice for the full wholesale price will be
owed by the Practice.

By selecting this checkbox, I hereby affirm my agreement to adhere to the aforementioned terms. Any deviation from or non-compliance with these terms shall render me responsible for any expenses related to the loaner unit.*