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
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?
About hours
Usage of prosthesis
(* Multiple answers allowed)
Everyday LifeRequired
Prosthesis Mfg. / Person in chargeRequired (Please note that we will contact the prosthesis manufacturer in charge.)