"*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Would you like to talk with another amputee who uses a Slingshot Socket™, and hear how it has changed their life? Our Slingshot Socket™ Experts look forward to connecting with you. Medicare, VA, and Insurance ApprovedWho do we have the pleasure of talking with?Name* First Last Email* Phone*Zip CodeWhich best describes you?Which Best Describes You?*Select OneAbove Knee or Knee Disarticulation AmputeeBelow Knee or Symes AmputeeAbove Elbow or Below Elbow AmputeeHip Disarticulation or Hemipelvectomy AmputeeShoulder Disarticulation or Forequarter AmputeeI am a ProsthetistI am a Family Member of an AmputeeOtherPlease Specify "Other"What questions can we answer for you?Ask Us a Question About Your SocketYour world is about to get a whole lot more comfortable! Help us get to know you, so we know how to best serve you.How old is your current socket?* < 6 Months 6 Months - 2 Years 2 Years I am a new amputee or don’t have a socket What issues do you have with your current socket?* Pain or Discomfort Restricted Range of Motion Skin Breakdown or Blisters Worn or Broken Difficulty Managing Fit Uncomfortable While Sitting Weight Loss or Gain Pistoning or Lack of Suspension Instability Excess Heat and Sweat None / No Socket Cause of Amputation*See OptionsTraumaVascular/DiabetesCongenitalCancerOther Your ComfortWe’ve found that if someone can be fit in a conventional socket, they should be able to be fit in a Slingshot Socket, typically with a lot more comfort.Which Slingshot Socket qualities are you most interested in experiencing?* I want a cooler and more breathable socket I want more comfort and conformity I want unrestricted range of motion I want a self-adjustable socket I want to regain my quality of life I want better sitting comfort What do you hope to be able to do now with a more comfortable socket? Fitting OptionsWe are excited for you to experience the most comfortable socket you’ve ever worn. Select which fitting option you’d prefer. Preferred fitting method can be changed at any time.Option 1: I’m interested in possibly coming to a Slingshot Clinic Option 1: I’m interested in possibly coming to a Slingshot Clinic We have more experience in fitting Slingshot Sockets™ than anyone – and we know how to maximize your comfort. Most fittings are completed in a single appointment or single day.Option 2: Send me to a Prosthetist that is already trained and experienced in fitting the Slingshot Socket. Option 2: Send me to a Prosthetist that is already trained and experienced in fitting the Slingshot Socket. We have trained hundreds of Prosthetists across the country, and can connect you with one that is already trained and experienced in fitting the Slingshot Socket™.Option 3: Get my local Prosthetist trained. Option 3: Get my local Prosthetist trained. Not all Prosthetists are progressive with new technology, but if yours is, we’d love to get them trained and support your fitting.Option 4: I just have questions, or not sure yet which path is best for me. Option 4: I just have questions, or not sure yet which path is best for me. Our Slingshot Experts are ready to answer all of your questions.Would you like us to check your prosthetic coverage now?* Yes, check my insurance now No thanks, I just have questions Insurance DetailsOur insurance verification team will determine your benefits and help get you the lowest out-of-pocket cost for the Slingshot Socket™.What Insurance Would You be Using?* Medicare Medicaid United Health Care VA VOC Rehab Workman’s Comp Blue Cross Blue Shield Aetna Cigna Other What other insurance/payment method?Do You Have Secondary Insurance?* Yes No What other secondary insurance/payment method?Do You Already Have a Prescription?* Yes No Upload Any Images You HaveYour insurer requires us to have these on file. If you don’t have them now, or want to talk with a Slingshot Expert first, simply click on the option below.Upload Any Images You Have Upload Images Now Talk to a Slingshot Socket™ Expert Upload Later Images can alternatively be emailed to info@SlingshotBionics.com if you prefer.Upload Front and Back Images of Your Insurance Card*Max. file size: 128 MB. Upload Image of Your Driver’s License or ID*Max. file size: 128 MB. Upload a Copy of Your Prescription From Your Doctor*Max. file size: 128 MB. Upload Images of Your Residual Limb and Current Prosthetic (optional)Max. file size: 128 MB. Consent* Yes, I Agree With The Privacy Policy And Terms And Conditions. By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging. Message frequency may vary. Reply HELP for more information. You can reply STOP to opt-out of further messaging.
