Form for preparation of your appointment

If you want to be considered for a paper intake then the request is to complete the questionnaire.
We will give you a message within 3 working days.


Name: *
Email address: *
Phone number: *
Date of birth: *
Nationality: *
Health insurance: *
Date of amputation:
Your amputation level: *
Cause of amputation: *
Question/Comment:
 
Verification: *