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.
State / Region
Level of amputation
Which Leg is Amputated?
Foot Size (in centimeters)
How did you lose your leg?
Anything else you want to tell us?
Send me a copy of my responses.
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