Register a new case

Name

Surname

Country

City

Residence address

Date of birth

Nationality

Gender

Have you ever had a prosthesis installed before?

Amputee Reason

Amputation type

Date of amputation

E-mail

Phone number

An alternate phone number

Whatsapp number

Other information

Select a photo of your amputated limb from your device

Choose the amputation image

For assistance, please contact the center through the number: 00905516895722