Name of Clinic

Phone

Shipping Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email for all communications *

Patient Information

Name *

First

Last

Date of Birth

Gender

Side of Limb Difference

Cause Of Limb Difference

Date of Amputation

Any Phantom/Residual Pain

Hand Dominance

Level Of Limb Loss

Sensation Of Residual Limb

Are there any areas of pain in the residual limb?

Other Health Conditions

ROM Limitation Of Upper Limb(s)

Does the elbow joint of the residual limb hyperextend easily?

History of previous prosthesis usage:

Is the patient currently using a prosthesis?

Type(s) of current prosthetic(s)

Electric
Body Powered
Passive Hand
Activity Specific

Are there any tasks/activities the patient wants to perform but cannot complete with the current prosthesis?

Any areas of concern with the residual limb? (sc arring, wounds, extremely prominent areas, skin grafts, etc.)

Does the patient have any allergies to materials?

General Notes:

Top down photo for sizing instructions

Step One:
- Clear a space on a flat surface.
Step Two:
- Place an 8x11 inch piece of paper under your patient's sound hand. If the patient has a bilateral limb difference, please make sure both residual limbs’ elbow joints are aligned with each other.
Step Three:
- Place an item on each of the patient's elbow creases. This can be done with string, a pencil, a ruler, a crayon, or by drawing a line in order to indicate where the elbow bend is on each of the patient's limbs.
Step Four:
- Take a picture of the patient with both arms outstretched in front of them and parallel (as seen in the reference photo below). It is important to capture the full length of the sound hand and residual limb (or both limbs if bilateral.

Please use the photos below as a reference guide:

Please upload photos and 3D scanning files if you didn't use the Unlimited Tomorrow 3D scanning app. *

Click or drag files to this area to upload. You can upload up to 5 files.

Please complete and submit the following measurements:

(A) Measurement

(B) Measurement

(C) Measurement

(D) Measurement

(E) Measurement

(F) Measurement

(G) Measurement

(H) Measurement

(I) Measurement

(J) Measurement

Sign to confirm that the file(s) are your own original work *

Cookie	Duration	Description
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Clinical Intake Form

Patient Information

Top down photo for sizing instructions

Please use the photos below as a reference guide:

Please complete and submit the following measurements:

Connect With Us

Join Our Newsletter