NOTE: This is NOT a secure site. We do not recommend you use a patient's name, but rather an identification code to comply with HIPAA regulations. 
Information marked with an asterisk ( * ) is required. 
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Patient Information

Customer Information

R01 R05 R09 R13 R17 R21 R25 R29 R33 R37 R41 R45 R49 R53 R57 R61 K1 K2 K3 K4 K5 K6 K7 K8 K9 K10 K11 K12 K13 K14 K15 K16 K17 K18 K19 K20 K21 K22 K23 K24 K25 K26 K27 K28 K29 K30 K31 K32 K33 *

Note:  Select color that is one shade lighter than required to match patient's skin tone.  Final matching of the patient's skin tone is best performed after you receive the prosthesis

Select the mechanical hand listed below for which the glove is being sized. If the mechanical hand is not listed in the chart, it must be sent in with the order so that REALASTIC® can fit it with the proper glove.  Most European hands should be sent to REALASTIC® for selection, fit, and installation of glove.