Male:    
Female:  
Name:    
Phone:   
Fax:     
Email:   
Address: 
City:    
State:    
Zip: 	 
Country: 

What type of prosthesis are you interested in?  

Finger 
Multiple fingers 
Hand/partial hand 
Below elbow arm 
Above elbow arm 
Toe 
Multiple toes 
Foot/partial foot 
Below knee prosthesis 
Above knee prosthesis 
Other 




If other, specify:   

Are you currently wearing a prosthesis? Yes No

Please describe in detail how you you became an amputee.
Also describe the current status of your residual limb(s).
 

Date of onset:       
Date of last surgery:

How would you like us to contact you?  It does not matter Phone Fax E-mail Letter Do not contact me 
Would you like us to mail you a brochure also? Yes No

How did you hear about us?  Doctor Therapist Case Manager Another amputee Friend Prosthetist Nurse Support Group Advertisement Internet Tradeshow Other 
If other, please specify: