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TRYING

If you would like to try on a prosthesis, please fill out the form below.
The person in charge will contact you at a later date.
If you have any other inquiries, please contact us from here.

Full NameRequired
Phone Number
Email AddressRequired
Your Area (prefecture)Required
Age years
weight (kg)Required kg
Height (cm)Required cm
Prosthesis history (years of use)Required years
Amputated LimbRequired
Foot TypeRequired
Types of Knee Joints (for those who have them)Required
(If you are unsure, please write [Unknown].)
Prosthesis usage:
How many hours do you use a day?
Required
About hours
Usage of prosthesis
(* Multiple answers allowed)
Required
Everyday LifeRequired
Prosthesis Mfg. / Person in chargeRequired