Customer Intake Form

Step 1: Complete the Customer Intake Form

Name(Required)
MM slash DD slash YYYY
Level of Amputation(Required)

Activities
Please check the activities that you are able to do safely and independently (without an assistive device).
Do you currently have any other medical conditions or co-morbidities that will affect your ability to exercise that we should be aware of?
This field is for validation purposes and should be left unchanged.