Patient Name* First Last Email* Phone*Today's Date* Delivery Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Surgery* Enter the date when you had the surgery, or your planned surgery date.Nature of Injury*AnkleFootAchilles TendonOtherIs This A Worker's Comp Related Injury?*YesNoFoot Immobilized By*Hard CastSoft CastBraceOtherPatient Height Inches*Patient Weight lbs*Patient Gender*MaleFemalePatient AgeLevel of Coordination*High - Skilled Sportsman, Runner, Skater, Skier, Basketball, Exercise machines, EtcMedium - Active Life style But No SportsLow - Physically InactiveTaking medications that make patient dizzy or light-headed?*YesNoIntended use of RollerFoot* At Home At Work Outside Other Predominant surface to be used on?* Hard smooth floor Carpeted floor Sidewalk Estimated Rental Period*3 weeks5 weeks6 weeks or longerI, Customer, mentioned above, voluntarily accept this Waiver and Assumption of Risk in favor of the Step Dynamics, LLC, in consideration for the opportunity to use / rent / buy RollerFootTM (Product). I understand that there are certain risks and dangers associated with the use of the Product and these risks have been fully explained to me. I fully understand the danger involved. I fully assume the risks involved as acceptable to me and I agree to use my best judgment in using the Product and follow all safety instructions. I waive and release Step Dynamics, LLC from any claim for personal injury, property damage, or death that may arise from my use of the Product. I am competent adult and I assume these risks of my own free will.* Yes, I agree and Accept this Waiver and Assumption of Risk NameThis field is for validation purposes and should be left unchanged.