Order Form

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1Practitioner Info

2Order Products

Practitioner Name*

First Last

Practitioner's Phone*

Practitioner's Email*

Clinic Name*

Accounts Payable Email*

Bill To

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Address*

Billing address same as shipping address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Product List

Order Information

Purchase Order # (required)*

Socket ID#

If provided by Martin Bionics

Patient Name*

Special Instructions

Select Products to Order Below - View Product List

Lower Extremity Products

SwingBrim™

[L] SwingBrim™

Please enter a number from 0 to 50.

Left Quantity

[R] SwingBrim™

Please enter a number from 0 to 50.

Right Quantity

AK cX-Hybrid Socket-less Socket™

[L] AK cX-Hybrid™

Please enter a number from 0 to 50.

Left Quantity

[R] AK cX-Hybrid™

Please enter a number from 0 to 50.

Right Quantity

AK cX-Hybrid Ordering Options*

Socket-less Socket™ Only

I'm sending a well-fitting check socket for Martin Bionics to assemble the Socket-less Socket™

I'm sending a cast for Martin Bionics to make a check socket (additional cost) and assemble the Socket-less Socket™

AK cX-Hybrid Final Fabrication*

After diagnostic fitting, I will return the adjusted check socket to Martin Bionics for final fabrication (additional cost, *separate order required*)

I will produce my own definitive socket

Add flexible inner socket? (additional cost)

Yes

Special Instructions

Color, preferred layup, materials, desired suspension, etc.

Components sent with the check socket

Patient Weight

ICON BK-Hybrid Socket-less Socket™

[L] ICON BK-Hybrid Socket-less Socket™

Please enter a number from 0 to 50.

Left Quantity

[R] ICON BK-Hybrid Socket-less Socket™

Please enter a number from 0 to 50.

Right Quantity

Mid Patellar Tendon to End of Limb Measurement (cm)*

Please enter a number greater than or equal to 0.

ICON BK-Hybrid Ordering Options*

Socket-less Socket™ Only

I'm sending a well-fitting check socket for Martin Bionics to assemble the Socket-less Socket™

I'm sending a cast for Martin Bionics to make a check socket (additional cost) and assemble the Socket-less Socket™

ICON BK-Hybrid Final Fabrication*

After diagnostic fitting, I will return the adjusted check socket to Martin Bionics for final fabrication (additional cost, *separate order required*)

I will produce my own definitive socket

Special Instructions

Color, preferred layup, materials, desired suspension, etc.

Components sent with the check socket

Patient Weight

Lateral Stabilizer

(provides additional lateral stability for short limbs or a replacement for a Silesian Belt)

[QTY] Lateral Stabilizer

Please enter a number from 0 to 50.

Quantity

Hip Disarticulation Products

Bikini Socket™ Iliac Crest Stabilizer Kit

(includes 2 ICS pads)

[QTY] Bikini Socket™ Iliac Crest Stabilizer

Please enter a number from 0 to 50.

Quantity

Bikini Socket™ Hammock Casting Stand

[QTY] Bikini Socket™ Hammock Casting Stand

Please enter a number from 0 to 50.

Quantity

Fabric to Socket Buckle

[QTY] Fabric to Socket Buckle

Please enter a number from 0 to 50.

Quantity

NASA Based 2-D Mesh (1 yard)

[QTY-H] NASA Based 2-D Mesh

Please enter a number from 0 to 50.

Quantity

Final Fabrication Only

Below Knee

[QTY] Below Knee

Please enter a number from 0 to 50.

Quantity

Above Knee

[QTY] Above Knee

Please enter a number from 0 to 50.

Quantity

Hip Disarticulation

[QTY] Hip Disarticulation

Please enter a number from 0 to 50.

Quantity

Special Instructions (if needed)

Other Products

Shark Skin Suspension

(box of 5 strips & 6 snowmen)

[QTY] Shark Skin Suspension

Please enter a number from 0 to 50.

Quantity

NASA Based 2-D Mesh (1 yard)

[QTY] NASA Based 2-D Mesh

Please enter a number from 0 to 50.

Quantity

HealthySkin™

[QTY] HealthySkin™

Please enter a number from 0 to 50.

Quantity

Gluteal Pads

[QTY] Gluteal Pads

Please enter a number from 0 to 50.

Quantity

Fabric Shoulder Socket Fabrication Kit^™

[QTY] Fabric Shoulder Socket Fabrication Kit

Please enter a number from 0 to 50.

Quantity

Martin Bionics Magnetic Buckle Set

[QTY] Martin Bionics Magnetic Buckle Set

Please enter a number from 0 to 50.

Quantity

Spare Parts Kit

(one bag is included with your AK or BK Socket-less Socket™ order)

Hidden

AK Parts Quantity

Quantity	Item
2	3/16" Truss Nut
3	3/16" Ultra-Low Pro SHCS
2	1/4" Ultra-Low Pro SHCS
2	1/4" Truss Nut
3	1/4" Flanged Button Head Cap Screw
2	5/16" Truss Nut
2	3/8" Truss Nut
7	3/8" Flanged Button Head Cap Screw
2	7/16" Truss Nut
2	1/2" Truss Nut
2	9/16" Truss Nut
2	5/8" Truss Nut
2	3/4" Truss Nut
8	Thumb Screws w/ Logo
2	2" Dot, Double-Sided Hook
1	1" Dot, Double-Sided Hook
1	Flow Ratcheting Buckle
1	Flow Ladder Strap
2	Junior ICON Petal, Full Length
2	Adult ICON Petal, Full Length
2	Holed Cross Connector, Full Length
8	Smooth Cross Connector, Full Length
2	Nylon Washer, 1.0" OD
1	Velcro Washer, Hook
1	Loctite, Single Use
1	AK Aluminum Bar, 16 Hole
1	AK Aluminum Bar, Bent 16 Hole
1	SharkSkin Suspension Kit
1	L-Hex Key Wrench, 3/16"
1	L-Hex Key Wrench, 1/8"
1	L-Hex Key Wrench, 3/32"

Please enter a number from 0 to 50.

Hidden

BK Parts Quantity

Quantity	Contents
2	3/16" Truss Nut
3	3/16" Ultra-Low Pro SHCS
6	1/4" Ultra-Low Pro SHCS
8	1/4" Flanged Button Head Cap Screw
2	1/4" Truss Nut
2	5/16" Truss Nut
12	3/8" Flanged Button Head Cap Screw
2	3/8" Truss Nut
2	7/16" Truss Nut
2	1/2" Truss Nut
2	9/16" Truss Nut
2	5/8" Truss Nut
2	3/4" Truss Nut
10	Thumb Screws w/ Logo
2	Adult ICON Petal, Full Length
3	Junior ICON Petal, Full Length
10	Smooth Cross Connector, Full Length
2	Holed Cross Connector, Full Length
2	BK Aluminum Bar
1	Egg Pad
2	Circle Pad
2	Velcro Washer
1	Flow Ratcheting Buckle
1	Flow Ladder Strap
1	SharkSkin Suspension Kit
1	L-Hex Key Wrench, 3/32"
1	L-Hex Key Wrench, 1/8"
1	L-Hex Key Wrench, 3/16"
1	Loctite, Single Use

Please enter a number from 0 to 50.

Deluxe Spare Parts Bag

(one bag included with your AK or BK Socket-less Socket™ order for in-house final fabrication)

Hidden

AK Deluxe Quantity

Quantity	Item
4	3/16" Truss Nut
4	3/16" Ultra-Low Pro SHCS
4	1/4" Ultra-Low Pro SHCS
4	1/4" Truss Nut
10	1/4" Flanged Button Head Cap Screw
12	5/16" Truss Nut
10	3/8" Truss Nut
20	3/8" Flanged Button Head Cap Screw
10	7/16" Truss Nut
15	1/2" Truss Nut
10	9/16" Truss Nut
8	5/8" Truss Nut
4	3/4" Truss Nut
8	Thumb Screws w/ Logo
2	2" Dot, Double-Sided Hook
1	1" Dot, Double-Sided Hook
1	Flow Ratcheting Buckle
1	Flow Ladder Strap
2	Junior ICON Petal, Full Length
2	Adult ICON Petal, Full Length
2	Holed Cross Connector, Full Length
8	Smooth Cross Connector, Full Length
2	Nylon Washer, 1.0" OD
1	Velcro Washer, Hook
1	Loctite, Single Use
1	AK Aluminum Bar, 16 Hole
1	AK Aluminum Bar, Bent 16 Hole
1	SharkSkin Suspension Kit
1	L-Hex Key Wrench, 3/16"
1	L-Hex Key Wrench, 1/8"
1	L-Hex Key Wrench, 3/32"

Please enter a number from 0 to 50.

Hidden

BK Deluxe Quantity

Quantity	Item
13	3/16" Truss Nut
6	3/16" Ultra-Low Pro SHCS
14	1/4" Ultra-Low Pro SHCS
13	1/4" Flanged Button Head Cap Screw
13	1/4" Truss Nut
10	5/16" Truss Nut
20	3/8" Flanged Button Head Cap Screw
13	3/8" Truss Nut
19	7/16" Truss Nut
11	1/2" Truss Nut
4	9/16" Truss Nut
4	5/8" Truss Nut
4	3/4" Truss Nut
10	Thumb Screws w/ Logo
2	Adult ICON Petal, Full Length
3	Junior ICON Petal, Full Length
10	Smooth Cross Connector, Full Length
2	Holed Cross Connector, Full Length
2	BK Aluminum Bar
1	Egg Pad
2	Circle Pad
2	Velcro Washer
1	Flow Ratcheting Buckle
1	Flow Ladder Strap
1	SharkSkin Suspension Kit
1	L-Hex Key Wrench, 3/32"
1	L-Hex Key Wrench, 1/8"
1	L-Hex Key Wrench, 3/16"
1	Loctite, Single Use

Please enter a number from 0 to 50.

End Section

Ship your cast or check socket to:

Martin Bionics
Attn: Fabrication
214 East Main Street
Oklahoma City, OK 73104

BK Deluxe: {BK Deluxe Quantity:241}

Comments

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(844) 624-6642
info@martinbionics.com

CORPORATE HEADQUARTERS:

214 E Main St
Oklahoma City, OK 73104

Clinical Care Locations:

1005 E St Elmo Rd Building 9
Austin, Texas
(512) 916-9431
Fax: (512) 916-9435
850 W John Carpenter Freeway
Irving, Texas
(214) 346-4135
Fax: (214) 346-4142
14201 Bruce B Downs Boulevard
Tampa, Florida
(813) 971-1100
Fax: (813) 971-9300
214 E Main St
Oklahoma City, OK 73104
(405) 803-8175
Fax: (405) 594-6500
And more to come
250+ Clinical Network Locations

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Order Form

Order Information

Lower Extremity Products

SwingBrim™

AK cX-Hybrid Socket-less Socket™

ICON BK-Hybrid Socket-less Socket™

Lateral Stabilizer

Hip Disarticulation Products

Bikini Socket™ Iliac Crest Stabilizer Kit

Bikini Socket™ Hammock Casting Stand

Fabric to Socket Buckle

NASA Based 2-D Mesh (1 yard)

Final Fabrication Only

Below Knee

Above Knee

Hip Disarticulation

Other Products

Shark Skin Suspension

NASA Based 2-D Mesh (1 yard)

HealthySkin™

Gluteal Pads

Fabric Shoulder Socket Fabrication Kit™

Martin Bionics Magnetic Buckle Set

Spare Parts Kit

Deluxe Spare Parts Bag

End Section

CORPORATE HEADQUARTERS:

Clinical Care Locations:

Stay Connected

Fabric Shoulder Socket Fabrication Kit^™