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
Last Name
Country
City
State / Region
Age (Years)
Height
Weight
Occupation
Yearly Income
Date Amputated
MM
/
DD
/
YYYY
Level of amputation
Clear selection
Which Leg is Amputated?
Clear selection
Foot Size (in centimeters)
Activity Level
Clear selection
Current Transport
Clear selection
How did you lose your leg?
Anything else you want to tell us?
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