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 passive hand listed below for which the glove is being sized. All sizes indicated are those of the passive hand without a glove on it.  Add 1/4 inch to the circumference measurements which are indicated below for the size of the hand and glove together.