Order Form

"*" indicates required fields

1Practitioner Info

2Order Products

Practitioner Name*

First Last

Practitioner's Phone*

Practitioner's Email*

Clinic Name*

Accounts Payable Email*

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

Order Information

Purchase Order # (required)*

Socket ID#

If configured on Socket-Soft™ or provided by Martin Bionics

Patient Name

Select Products to Order Below

Upper Extremity Products

ICON Above Elbow Socket-less Socket^™

[R] ICON Above Elbow Socket-less Socket™

Please enter a number from 0 to 50.

Right Quantity

[L] ICON Above Elbow Socket-less Socket™

Please enter a number from 0 to 50.

Left Quantity

ICON Below Elbow Socket-less Socket^™

[R] ICON Below Elbow Socket-less Socket™

Please enter a number from 0 to 50.

Right Quantity

[L] ICON Below Elbow Socket-less Socket™

Please enter a number from 0 to 50.

Left 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

Special Instructions

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

Hip Disarticulation Products

Bikini Socket™ Iliac Crest Stabilizer

[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

Lower Extremity Products

Lateral Stabilizer

[QTY] Lateral Stabilizer

Please enter a number from 0 to 50.

Quantity

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 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 ($475) and assemble the Socket-less Socket™

AK cX-Hybrid Check/Cast Socket Options*

I will return the assembled check socket for Martin Bionics to do final fabrication ($1,595) after I complete the diagnostic fitting.

I will produce my own definitive socket.

Add flexible inner socket? ($250)

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 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 ($475) and assemble the Socket-less Socket™

ICON BK-Hybrid Check/Cast Socket Options*

I will return the assembled check socket for Martin Bionics to do final fabrication ($1,595) after I complete the diagnostic fitting.

I will produce my own definitive socket.

Special Instructions

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

Components sent with the check socket

Patient Weight

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

Spare Parts Kit

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

Hidden

AK 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 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}

Phone

This field is for validation purposes and should be left unchanged.

Order Form

Order Information

Upper Extremity Products

ICON Above Elbow Socket-less Socket^™

ICON Below Elbow Socket-less Socket^™

Fabric Shoulder Socket Fabrication Kit^™

Martin Bionics Magnetic Buckle Set

Hip Disarticulation Products

Bikini Socket™ Iliac Crest Stabilizer

Bikini Socket™ Hammock Casting Stand

Fabric to Socket Buckle

NASA Based 2-D Mesh (1 yard)

Lower Extremity Products

Lateral Stabilizer

SwingBrim™

AK cX-Hybrid Socket-less Socket™

ICON BK-Hybrid Socket-less Socket™

Other Products

Shark Skin Suspension

NASA Based 2-D Mesh (1 yard)

HealthySkin™

Spare Parts Kit

Deluxe Spare Parts Bag

End Section

LoveYour Socket™ Comfort Mobility Independence Freedom Life

EXPECT

COMFORT

844-MBIONIC

624-6642

CORPORATE HEADQUARTERS:

Clinical Care Locations:

Stay Connected

You're Just Steps Away From More Comfort!

Let our Socket-less Socket™ Experts Help you Discover Comfort.

Order Form

Order Information

Upper Extremity Products

ICON Above Elbow Socket-less Socket™

ICON Below Elbow Socket-less Socket™

Fabric Shoulder Socket Fabrication Kit™

Martin Bionics Magnetic Buckle Set

Hip Disarticulation Products

Bikini Socket™ Iliac Crest Stabilizer

Bikini Socket™ Hammock Casting Stand

Fabric to Socket Buckle

NASA Based 2-D Mesh (1 yard)

Lower Extremity Products

Lateral Stabilizer

SwingBrim™

AK cX-Hybrid Socket-less Socket™

ICON BK-Hybrid Socket-less Socket™

Other Products

Shark Skin Suspension

NASA Based 2-D Mesh (1 yard)

HealthySkin™

Spare Parts Kit

Deluxe Spare Parts Bag

End Section

LoveYour Socket™ Comfort Mobility Independence Freedom Life

EXPECT

COMFORT

844-MBIONIC

624-6642

CORPORATE HEADQUARTERS:

Clinical Care Locations:

Stay Connected

You're Just Steps Away From More Comfort!

Let our Socket-less Socket™ Experts Help you Discover Comfort.

ICON Above Elbow Socket-less Socket^™

ICON Below Elbow Socket-less Socket^™

Fabric Shoulder Socket Fabrication Kit^™