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Part 1: 3D Printed Prosthetic Fitting

Questions 1 to 10

Complete the form below.

Write ONE WORD AND/OR A NUMBER for each answer.

Nova Prosthetics – Patient Registration Form

Patient Details

  • Surname: 1 ………………..
  • Occupation: 2 ………………..

Prosthetic Requirements

  • Specific body part for fitting: left 3 ………………..
  • Preferred socket material: 4 ………………..
  • Chosen strap colour: 5 ………………..

Appointment Information

  • Date of first measurement: 14th 6 ………………..
  • Time of session: 7 ……………….. am
  • Required clothing: wear loose 8 ………………..
  • Document to bring: original physical 9 ………………..

Clinic Location

Main entrance is located on: 10 ……………….. Street