If you are in need of a prosthetic donation, please fill out the following form and Limbs of Hope will contact you shortly.

Name
first name
last name
Address
street
city
state or providence
postal code
country
Date of Birth
month
day
year
Contact Info
phone
email

Amputee Type AKA BKA AEA BEA
  both  
Measurements for Prosthetic(s): Check with your doctor.
size of hand or foot
BKA or BEA: elbow to wrist or knee to ankle
AKA or AEA: shoulder to wrist or hip to ankle
Length of residual stump
Weight
Size around stump
Doctor's Name
Doctor's Phone
Doctor's Address
How did you become and amputee?
How can Limbs of Hope help and why?
How did you hear about us?
Any information provided to The Limbs of Hope will be kept confidential