Member Details

As part of our ongoing efforts to improve our service, we would like to invite you to complete the following form, so that we can better support you in future.

Please note: this information will be stored securely and will not be passed on to anyone else.

    Level of Amputation

    Please check any boxes that apply

    Left arm: above elbowLeft arm: below elbowLeft arm: below wristRight arm: above elbowRight arm: below elbowRight arm: below wristLeft leg: Above kneeLeft leg: Below kneeRight leg: Above kneeRight leg: Below kneeDiabetesVascular DiseaseOsseointegrationDigit(s)

    Amputation Foundation require the following information, to be able to provide you with information that may be relevant to your rehabilitation, support and health and wellbeing.

    By submitting this form, you agree for your information to be stored securely by Amputation Foundation for the reasons outlined above.

    Amputation Foundation Logo
    Amputation Foundation
    Unit 3 Ruskin Leisure,
    Ruskin Drive,
    Dentons Green,
    St Helens,
    WA10 6RP
    CALL 01744 808 850