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Need a Prosthesis?

Prosthetist Form for USA

First Name *
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
First Name *
Last Name *
Professional level of prosthetist (check all that apply)
Prosthetist Agreement: By signing below, I confirm my commitment to ROMP's work of providing high-quality prosthetic care to people with amputation facing barriers to receiving this service. The information I have provided is true to the best of my knowledge, and I authorize ROMP to work directly with me to facilitate the prosthetic care of patients in the US Assistance Program.

Patient Information

Month
/
Day
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Year
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Patient Gender
Level of Amputation
Side of Amputation
Patient Activity Level
Cause of Amputation
Month
/
Day
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Year
Patient Medical Conditions
What criteria does the patient meet to apply for USAP? (Select all that apply)
Patient Agreement #1: Do you understand, and agree to, the co-payment for your prosthetic care, as explained by your US Assistance Program Prosthetist? / ¿Entiende usted, y está usted de acuerdo con el co-pago para su atención protésica, tal como se describe su protetista del Programa de Asistencia?
Patient Agreement #2: Do you understand, and agree, that you will receive used or recycled componentry and ROMP does not provide any guarantee as to its usability or proper operation either alone or within your prosthetic device. / ¿Entiende usted, y está de acuerdo con que recibirá componentes usados ​​o reciclados y ROMP no ofrece ninguna garantía en cuanto a su durabilidad o funcionamiento adecuado, ya sea solo o dentro de su dispositivo protésico?

Our Impact Since 2005

  • Years Breaking Barriers

    19

  • Prosthetic Devices Delivered

    5,165

  • Patient Visits

    15,816

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