Complete the information below to have your submission reviewed for a chance to be featured on Hanger Clinic’s Recognition Board and social media channels. Both you and the person you are recognizing do not have to be Hanger Clinic patients to participate.
NOTE: The only information that will be published from this form is your name, the name of the person you are recognizing, your submission, and select photos you share.

For any questions, please reach out to To learn more about the Amputee Coalition and other ways to get involved during LLLDAM, visit the resource here.

Background and Contact Information:
Are they a Hanger Clinic patient? Note: This question is to determine if they need to sign an additional PR HIPAA release form. *
Submission Materials:

Consent Forms:
Have you signed the Media / Photo Release form below, which allows us to share your submission publicly? (The release is required to participate.)

Media Release *
Are you a Hanger Clinic patient? *
If “yes,” you are a Hanger Clinic patient, you also need to sign the PR HIPAA release form below. (Required)
PR HIPAA Release
Check below if you would like to receive updates from Propel, Hanger Clinic’s patient blog. *
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