Prosthetic Leg Request Form
If you live outside of the United States, have a low income, and are in need of a prosthetic leg, please fill out this form. We only have services in a few areas of the world right now, but if we have services in your area and are able to assist, we will contact you with details of our next trip to your area. If we ever open services in your area, we will reach out to you at that point.
Email address *
First Name
Your answer
Last Name
Your answer
Country
Your answer
City
Your answer
Age (Years)
Your answer
Height
Your answer
Weight
Your answer
Occupation
Your answer
Yearly Income
Your answer
Date Amputated
MM
/
DD
/
YYYY
Level of amputation
Which Leg is Amputated?
Foot Size (in centimeters)
Your answer
Activity Level
Current Transport
How did you lose your leg?
Your answer
Anything else you want to tell us?
Your answer
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