Gender:*
    Male:    
    Female:  

Name:*    
Phone:*   
Fax:     
Email:*   

Address: 
City:    
State:    
Zip: 	 
Country: 

What type of prosthesis are you interested in? * 
 

Hand 

Hand/partial hand 
Finger
Multiple fingers 
Below elbow arm 
Above elbow arm 
Toe 
Multiple toes 
Foot/partial foot 
Below knee prosthesis 
Above knee prosthesis 

Other 



If other, specify:   

Are you currently wearing a prosthesis?* Yes No

Please describe in detail how you you became an amputee.*
Also describe the current status of your residual limb(s).
 

Date of onset:       
Date of last surgery:

How would you like us to contact you? *  
It does not matter Phone Fax E-mail Letter Do not contact me 

Would you like us to mail you a brochure also?* Yes No

How did you hear about us? *  Doctor Therapist Case Manager Another amputee Friend Prosthetist Nurse Support Group Advertisement Internet Tradeshow Other 

If other, please specify:

         

		
 
     
     
 
	  
	 
     
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