LEAP Kit Order Form for Consumers
Please complete this form to order your LEAP Kit.
LEAP Monofilament 0 1 2 3 4 5 6 7 8 9 10
Programa Para Prevenir la Amputacion de las Extremidades Inferiores - LEAP Foot Instruction (Spanish), PC00053
Please download instructions in English at http://www.hrsa.gov/leap/selftest.htm.
Please fill in the following information: (* indicates required information)
Prefix:
*First Name:
*Last Name:
Credentials:
Title:
Organization:
*Street
*City
*State
Please select a state for US orders. Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Is Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Province (required for international orders)
*Country
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*Zip
Phone
( ) -
Extension
Fax
E-mail
Please note:
If you are ordering from outside the U.S.A., please be sure to include an e-mail address.
*Profession:
Please choose. Administrator/Manager Clergy Dentist/Dental Hygienist Educator (College/University - including Medical School, Dental School, etc.) Educator (Daycare- Grade 12) General Public/Consumer Government Employee (Federal) Government Employee (State and Local) HRSA Staff Law Enforcement/Justice Librarian/Researcher Mental Health Care Provider NHSC professional/student Nurse Nurse Practitioner/Physician Assistant Other Other Clinician/Health Professional Parent/Expectant Parent Physician Student Student (College/University) Student (Daycare - Grade 12) Student (Unspecified) Volunteer
*Setting:
Please choose. Business College/University (including Medical School, Dental School, etc.) Community-Based Organization Consumer Education (Daycare - Grade 12) Faith-Based Organization Government (Federal) Government (State and Local) Health Center Health Resources and Services Administration(HRSA) Hospital/Clinic Library Local Health Department NHSC setting Other Other Health Care Professional Organization Tribal Governance Agency