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AMPOWER Peer Visit Request Form
I am:
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A Congenital Amputee
Facing Amputation
Considering Elective Amputation
A New Amputee
A Long-Time Amputee
A Loved-One of an Amputee (parent, partner, spouse, friend)
A Medical Professional
(Used for accurate peer matching)
Mr.
Ms.
Mrs.
Mx.
Name:
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Relationship to Amputee:
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Email Address:
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Phone Number:
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Name:
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Type of Provider:
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Hospital or Facility:
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Email Address:
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Phone Number:
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Are you currently working with a local AMPOWER coordinator?
*
Yes
No
Local AMPOWER Coordinator:
Contact Information
Your Loved One's Contact Information
Patient's Contact Information
Mr.
Ms.
Mrs.
Mx.
First Name:
*
Last Name:
*
Email Address:
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Phone Number:
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Address:
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City:
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State:
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AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code:
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Date of Birth
(00/00/0000)
*
+
Limb Loss or Limb Difference Details
Date of Amputation
(00/00/0000)
:
*
+
Hospital for amputation and operating surgeon:
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Limb Loss Type: (select one or more)
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Finger(s)
Partial Hand
Wrist Disarticulation
Below Elbow
Elbow Disarticulation
Above Elbow
Shoulder Disarticulation
Forequarter
Bi-lateral upper Limb (both arms affected)
Toe(s)
Partial Foot
Symes
Below Knee
Knee Disarticulation
Above Knee
Hip Disarticulation
Hemipelvectomy
Bi-Lateral Lower Extremity (both legs affected)
Triple Amputee (both legs and one arm affected)
Quadramembral Amputee (all four limbs affected)
Other
Other
Limb Loss Site:
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Left
Right
Bilateral
Trimemberal
Quadrimembral
Limb Loss Cause (Select one or more)
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Birth Defect/Congenital
Cancer
Chronic Infection
Diabetes
Injury/Trauma
Sepsis
Tuberculosis
Vascular Disease
Unknown
Work Accident
Other
Other
Please tell us about your primary concerns and questions:
*