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ROCKFORD -NORTHERN ILLINOIS- WISCONSIN

CHICAGOLAND- JUSTICE ILLINOIS

MUNSTER INDIANA

815-226-0444

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WE WILL HELP YOU REGAIN YOUR INDEPENDENCE WITH
COMFORT AND TECHNOLOGY

FILL THIS FORM FOR A FREE CONSULTATION

First Name

Last Name

Email

Phone

YOUR CONDITION THAT YOU NEED HELP WITH:

I AM A LOWER LIMB AMPUTEE

I AM AN UPPER LIMB AMPUTEE

I HAVE WEAKNESS OF LOWER OR UPPER LIMBS

I AM A PARIENT AND MY CHILD NEEDS PROSTHETIC /ORTHOTIC DEVICE

YOUR CONDITION THAT YOU NEED HELP WITH:

I AM A NEW PATIENT WHO NEEDS A CONSULTATION

I AM AN EXISTING PATIENT WHO NEEDS BETTER PROSTHETIC CARE

MY SOCKET IS UNCOMFORTABLE AND I NEED HELP

I HAVE A FAMILY MEMBER WHO NEEDS HELP WITH PROSTHESIS

I NEED TO GET EVALUATED FOR ADVANCED TECHNOLOGY

I WANT TO KNOW MORE ABOUT THE -C BRACE

I NEED HELP WALKING

I NEED AN UPPER LIMB PROSTHESIS

HOW CAN WE HELP YOU?

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815-226-0444

2629 Charles Street

Rockford IL 61108

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