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Patient Application Form
Personal Information
Full Name
Date of Birth / Age
Gender
Male
Female
Other
Address
Contact Number
Email (Optional)
Emergency Contact
Medical Information
Type of Disability / Condition
Amputation
Polio
Deformity
Other
Affected Area
Right
Left
Upper Limb
Lower Limb
Date of Disability / Injury
Cause of Condition
Previous Treatment or Surgery
Yes
No
Current Assistive Device Used
Yes
No
Height / Weight
Existing Medical Conditions
Diabetes
Hypertension
Other
Device Requirement
Type Required
Prosthesis
Orthosis
Side of Application
Left
Right
Bilateral
Location
Upper Limb
Lower Limb
Special Instructions
I hereby declare that the above information is true and authorize the Orthotics & Prosthetics Center to use this information for clinical and treatment purposes.
Signature / Thumb Impression
Clear Signature
Date
Note:
The information provided in this form will be used exclusively for clinical evaluation and treatment planning by the Prosthetics & Orthotics (P&O) team.
After a detailed assessment and check-up by the P&O professional, the appropriate course of treatment or device recommendation will be decided.
Submission of this form does not guarantee the provision of a prosthetic or orthotic device.
If the patient is found medically or technically unfit or unsuitable for the treatment, the P&O team reserves the right to decline or defer the case.
All patient details will be kept confidential and used only for professional and documentation purposes related to prosthetic/orthotic care.
