For healthcare professionals and hospitals. Please do not include a patient's name, medical records or other identifying details in this form. We will contact you about the appropriate referral process.

Your full name

Profession or role

Hospital or organisation

Email address

Phone number

Province or location

Reason for referral

Clinical assessmentPotential research participationClinical care and potential research participation

Current device used by the patient
—Please choose an option—Pattern RaiseStraight-Leg CalliperExtension ProsthesisOther PFFD deviceNo current deviceNot sure

Brief reason for referral
Please do not include the patient's name or other identifying information.

I confirm that I have not included patient-identifying information or medical records in this initial referral enquiry.