1. Patient Information

Full Name *

WhatsApp / Contact Number *

Email Address

Province *
Select provinceEastern CapeWestern CapeGautengKwaZulu-NatalFree StateLimpopoMpumalangaNorth WestNorthern Cape

Amputation Level *
Select amputation levelBelow-kneeAbove-kneeBilateral below-kneeBilateral above-kneeOther

Prosthetic Requirement *
Select requirementFirst prosthetic legNew replacement prosthetic legExploring future options

2. Monthly Payment Interest

LAOS is exploring instalment purchase
arrangements for new prosthetic legs.

Would you consider purchasing a
prosthetic leg through monthly payments?

YesMaybeNo

What monthly amount could you afford? *
Select monthly budgetR2,500R5,000R7,500Enter my own amount

If you selected your own amount,
enter it in Rand (minimum R1,500)

3. Preferred Payment Period

The minimum monthly budget is R1,500
for all three payment periods.

36 months - Standard48 months - Standard60 months - Extended Care

60-Month Extended Care Benefits

Available exclusively with new
LAOS-supplied prosthetic devices.

• One clinically indicated socket
  replacement during 60 months.

• One liner and/or sleeve annually,
  according to the suspension system.

• Two prosthetic socks annually.

• Scheduled maintenance and eligible
  repairs, subject to coverage limits.

• Standard LAOS services for the
  first 12 months.

• Applicable supplier-specific
  component warranties.

Are you interested in purchasing
a new LAOS-supplied prosthetic device?

YesMaybe - I need more informationNo - I only need servicing

4. Optional Initial Deposit

No initial deposit is compulsory
for this interest survey.

Would you consider paying an
initial deposit?

YesNoNot sure

Preferred deposit percentage *
Select deposit preference0% - No deposit10%15%20%Not sure yet

5. Payment Capacity and Readiness

Who would make the monthly payments? *
Select payerMyselfFamily memberEmployerSponsorOther

Employment Status
Select employment statusEmployedSelf-employedPensionerUnemployedOther

When would you need a prosthetic leg? *
Select timelineImmediatelyWithin 1-3 monthsWithin 3-6 monthsMore than 6 monthsJust exploring

Other Potential Funding Source
Select funding sourceMedical aidRAFCOIDAFamily supportNoneNot sureOther

6. Contact Preferences and Consent

Preferred Contact Method

WhatsAppPhone callEmail

Read our
Privacy Notice
before submitting.

I consent to LAOS processing the information provided for this enquiry and contacting me about the proposed monthly payment programme. I understand that this is market research, not a financing offer.

Optional Email Marketing Consent

Would you like to receive occasional emails
from LAOS about prosthetic and orthotic
products, rehabilitation services,
new programmes and special offers?

I agree to receive marketing emails from LAOS. I understand that I can unsubscribe at any time.

This is optional. Your decision
will not affect your enquiry or
eligibility for LAOS services.

Submitting this form does not
guarantee financing, approval, supply of
a prosthesis or Extended Care benefits.
All arrangements are subject to feasibility,
eligibility and applicable requirements.