If you would like to receive an information packet or schedule a free evaluation, please fill out and submit the form below.  You will receive your information packet or be contacted by a Prosthetic Center of Excellence representative within one week of submitting your request. 

If you do not wish to send a request on line, feel free to give us a call and speak with a PCE Representative at 1-800-883-6101.
 
2. Select any of the following options that apply:
First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

2. Select any of the following options that apply:
    Please contact me to schedule an evaluation
    Please send me an information packet