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AMPOWER Peer Visit Request Form
I am:
*
an individual who was born with limb loss / difference
facing amputation
considering elective amputation
an individual who has an amputation
a loved one of a person who has limb loss / difference
a medical professional
Your Contact Information
Dr.
Mr.
Ms.
Mrs.
Mx.
Name:
*
Relationship to Amputee:
*
Email Address:
*
Phone Number:
*
Preferred communication method:
*
Phone
Email
Name:
*
Type of Provider:
*
Hospital or Facility:
*
Email Address:
*
Phone Number:
*
Your Loved One's Contact Information
Patient's Contact Information
Mr.
Ms.
Mrs.
Mx.
First Name:
*
Last Name:
*
Email Address:
*
Phone Number:
*
Preferred communication method:
*
Phone
Email
Address:
*
City:
*
State:
*
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)
Limb Loss Type:
*
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)
*
Above Elbow
Below Elbow
Hand/Partial Hand
Above Knee
Below Knee
Hip Disarticulation
Foot/Partial Foot
Please specify which limb(s) are affected with each type of limb loss selected:
*
Type if Lower Limb Loss:
*
Above Knee
Below Knee
Hip Disarticulation
Foot/Partial Foot
Typr of Upper Limb Loss :
*
Above Elbow
Below Elbow
Hand/Partial Hand
Limb Loss Cause: (Select one or more)
*
Birth / Congenital
Cancer
Chronic Infection
Diabetes
Injury/Trauma
Sepsis
Vascular Disease
Work Accident
Other
Other
Date of Amputation
(00/00/0000)
:
*
+
Hospital for amputation and operating surgeon:
*
Are you currently working with a local AMPOWER coordinator?
*
Yes
No
Local AMPOWER Coordinator:
Please tell us about your primary concerns and questions:
*