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 *

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

if desired:

none R01 R05 R09 R13 R17 R21 R25 R29 R33 R37 R41 R45 R49 R53 R57 R61

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.