Enquiry form

ICON in Motion would appreciate it if you could fill in a screening questionnaire to assess your suitability for osseointegration treatment.

In order to be able to help you in the best possible way and to inform you about this treatment, it is important that you fill in the questionnaire as completely as possible. Think, for example, of your medical history and current medication.

Please fill in the form below to receive the questionnaire via e-mail.

What is the reason for the amputation?
Level of amputation
Complaints
General information
Where did you find us?

Download

Please fill in the form below to download the folder.

Thank you for filling in the details! The folder will be downloaded.

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