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AMPOWER Peer Visit Request Form
I am:
*
A Congenital Amputee
Facing Amputation
Considering Elective Amputation
An Amputee
A Loved-One of an Amputee
A Medical Professional
Mr.
Ms.
Mrs.
Mx.
Name:
*
Relationship to Amputee:
*
Email Address:
*
Phone Number:
*
Name:
*
Type of Provider:
*
Hospital or Facility:
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Email Address:
*
Phone Number:
*
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:
*
Phone Number:
*
Address:
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City:
*
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:
*
Date of Birth
(00/00/0000)
*
+
Limb Loss or Limb Difference Details
(Used for accurate peer matching)
Date of Amputation
(00/00/0000)
:
*
+
Hospital for amputation and operating surgeon:
*
Limb Loss Type:
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Upper Limb Loss
Lower Limb Loss
Bi, Tri or Quadrilateral Limb Loss
Please select all levels of Limb Loss that apply : (select one or more)
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Partial Hand
Below Elbow
Above Elbow
Partial Foot
Below Knee
Above Knee
Hip Disarticulation
Please specify which limb(s) are affected with each type of limb loss selected
Please specify which limb(s) are affected with each type of limb loss selected
Type if Lower Limb Loss:
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Below Knee
Above Knee
Hip Disarticulation
Typr of Upper Limb Loss :
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Partial Hand
Below Elbow
Above Elbow
Limb Loss Cause: (Select one or more)
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Birth Defect/Congenital
Cancer
Chronic Infection
Diabetes
Injury/Trauma
Sepsis
Vascular Disease
Work Accident
Other
Other
Please tell us about your primary concerns and questions:
*