SYNSYS New Inquiry / Measurement Form

If you have already received certification, please submit one of the following forms instead:

New Trial: SYNSYS Trial Certified Customer
New Order: SYNSYS Order Certified Customer

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? Consult the map above:
*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