Prosthetic Leg Request Form

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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 *

First Name

Last Name

Country

City

State / Region

Age (Years)

Height

Weight

Occupation

Yearly Income

Date Amputated

YYYY

Level of amputation

Above knee

Below knee

Other:

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Which Leg is Amputated?

Right

Left

Both

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Foot Size (in centimeters)

Activity Level

High

Medium

Low

Clear selection

Current Transport

Prosthetic

Crutches

Wheel Chair

Walker

Other:

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How did you lose your leg?

Anything else you want to tell us?

Send me a copy of my responses.

Submit

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