SYNSYS New Inquiry / Measurement Form

Thank you for your interest in the SYNSYS Microprocessor Full-Leg System.
SYNSYS is intended for adults with unilateral transfemoral amputation weighing between 99- 275lbs.
Please complete the following form to verify that the user meets all the conditions in terms of weight, activity, and available build height.

1. Who is your PROTEOR Sales Representative?
*This question is required.

2. Your First and Last Name *This question is required.

3. Your Email Address *This question is required. This question requires a valid email address.

4. Your /Clinic Phone Number *This question is required.

5. Clinic Name and Address: *This question is required.

6. Patient First Initial/Last Name, and/or PO *This question is required.

7. Amputation Side *This question is required.

8. Amount of external rotation of the foot required: *This question is required.

9. Activity Level *This question is required.

10. Patient Weight (including loads carried often) *This question is required.

11. Foot Size (cm) *This question is required.

12. What prosthetic knee does the patient currently wear? *This question is required.

Comments

13. What is the current/planned socket suspension? *This question is required.

Comments

Two measurements (in mm) are required to determine proper build height for SYNSYS, A and C below. Measurement A is knee center to floor and Measurement C is top of pyramid to floor without a shoe. Please round down to the nearest available measurement on the list. Please note that pictures will not be accepted, measurement values are required.

If the patient does not have a current prosthesis to take measurements from, please set up a "mock" prosthesis for measurement purposes.

15. Measurement C (in mm): Top of the pyramid to the floor without a shoe. Please measure carefully. Measurement must be between 467-587 mm. *This question is required. This question requires a valid number format.

16. First available date option you and your patient could schedule for the certification course and trail? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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17. Second available date option you and your patient could schedule for the certification course and trail? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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18. Third available date option you and your patient could schedule for the certification course and trail? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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19. Additional comments/information:

SYNSYS New Inquiry / Measurement Form

SYNSYS Microprocessor Full-Leg System NEW Inquiry / Measurement Form