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Need a Prosthesis?
Prosthetist Form for USA
Prosthetist Name
First Name *
Last Name *
Prosthetist Email
Prosthetist Phone Number
Clinic Name
Clinic Address (Components will be shipped here)
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Administrative contact name (Point of contact). We will be in contact with this person to make the appointments for the patient.
First Name *
Last Name *
Administrative contact phone number
Administrative Contact Email
Professional level of prosthetist (check all that apply)
Certified Prosthetist
Certified Orthotist
Resident Prosthetist
Resident Orthotist
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.
I agree
I do not agree
Patient Information
Patient Full Name
Patient Email
Patient Phone Number
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Patient Date of Birth
Month
January
February
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April
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Day
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Day
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Patient Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Patient Country of Origin
Patient Gender
Female
Male
Non-binary
Level of Amputation
Transfemoral (AK)
Transtibial (BK)
Side of Amputation
Left
Right
Patient Activity Level
K1
K2
K3
K4
Cause of Amputation
Trauma from Agricultural Accident
Trauma from Electrical Discharge
Trauma from Fire or Fireworks
Trauma from Industrial Accident
Trauma from Transit Accident (bus, motorcycle, car, bike, etc)
Trauma from Animal (bite, attack, etc)
Trauma from Natural Disaster (earthquake, mudslide, etc)
Trauma from Violence (gun, knife, other)
Disease of Arthritist
Disease of osteomyelitis
Disease of osteoporosis
Disease of osteosarcoma
Disease of septicemia
Disease of thrombosis
Disease of diabetic foot
Congenital
Other
Date of Amputation
Month
January
February
March
April
May
June
July
August
September
October
November
December
Month
/
Day
1
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Day
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Year
Height of Patient (feet & inches)
Patient Weight (lbs)
Patient Medical Conditions
Diabetes
Hypertension
Asthma
None
What criteria does the patient meet to apply for USAP? (Select all that apply)
Immigration-related barrier
Insurance-related barrier
Financial-related barrier
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?
Yes
No
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?
Yes
No
Our Impact Since 2005
Years Breaking Barriers
19
Prosthetic Devices Delivered
5,165
Patient Visits
15,816
Home
About Us
Mission & Vision
Impact
Global Team
Certifications
Contact Us
Get Involved
Donate
Monthly Mobility Member
Volunteer Programs
Prosthetic Recycling (C4C)
Partner
Work With Us
Need a Prosthesis?
Ecuador
Guatemala
USA
Campaigns & Events
LLAM Component Drive
Mobility May
Climbing for ROMP
Event Calendar
News & Media
Recent Press
Media & Film
Blog
Newsletter Signup
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