You must have JavaScript enabled to use this form. Brace Model Select Brace Model: A22 Defiance FullForce Armor FourcePoint Patient Info Brace Number: Part Number Locate your brace number for: A22, or Defiance. × Patient Name: Parent of minor: If patient is under 18 years of age, please provide the name of your parent or guardian. Address: Address 2: City: State: - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesNunavutYukon Zipcode: Country - Select -United StatesCanada Email Address: Phone Number Questionnaire Patient has registered brace within ninety days of purchase Yes No ACL re-tear occurred within the last ninety days? Yes No Patient is original purchaser of the brace Yes No Brace was purchased within 6 months of surgery Yes No This claim is within one year from the date of purchase of the brace? Yes No Patient has previously completely ruptured and had his/her ACL surgically repaired Yes No Patient is a US resident Yes No Brace has not been repaired or altered by anyone other than the manufacturer Yes No Has the brace been subject to misuse, neglect or accident Yes No Patient was wearing the brace indicated above at the time of the ACL re-tear Yes No Patient is an NCAA athlete Yes No The date of the original surgery The date of the re-injury (must be within 18 months of orig. injury) The date of any required second surgery Additional Information Name of surgical physician: Surgical Physician’s Phone Number: In detail please explain in detail how the complete re-tear of the ACL occurred (for ex: Playing basketball while wearing the brace, went for a layup and upon landing the knee twisted and felt a pop ) Note Please note: Once a claim is submitted, all necessary documents must be received no later than 90 days from submission date. Leave this field blank