APPLY

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WHO IS ELIGIBLE

  • Must be female, age 16 or older.

  • Must be a U.S. Citizen

  • Must have loss of one or more limbs.

  • Must fill out the application in its entirety.

  • Must have exhausted all insurance funding resources.

  • Must be presently wearing an arm (passive) or leg prosthesis on a daily basis or be in the process of being fitted by a certified prosthetist.

  • Must be able to travel to Dallas, Texas for a 2-3 day appointment with our provider.

 

APPLICATION

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Name (First, Middle, Last) *
Name (First, Middle, Last)
Date of Birth
Date of Birth
Address
Address
Marital Status
When did you lose your limb(s)?
When did you lose your limb(s)?
 
Name *
Name