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.
* Required
Email address
*
Your email
First Name
Your answer
Last Name
Your answer
Country
Your answer
City
Your answer
State / Region
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
Above knee
Below knee
Other:
Clear selection
Which Leg is Amputated?
Right
Left
Both
Clear selection
Foot Size (in centimeters)
Your answer
Activity Level
High
Medium
Low
Clear selection
Current Transport
Prosthetic
Crutches
Wheel Chair
Walker
Other:
Clear selection
How did you lose your leg?
Your answer
Anything else you want to tell us?
Your answer
Send me a copy of my responses.
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