Robohand Enquiry Form for Potential Candidate

Thanks for your interest in Robohand. Please complete the below form in full. Once we receive this information along with some close up photographs, back and front of both hands, and if possible a video of both hands being turned over and back again we will be able to process your request.

All fields are required and your application will not be considered if this form is not completed in full.

All costs EXCLUDE shipping, which is for the purchaser’s/receiver’s account.
South African prices apply only to orders to be shipped within South Africa and with payments made through a South African bank.
Dollar prices apply to orders from anywhere outside South Africa and all bank charges are to be covered by the purchaser.
Shipping costs must be ascertained before orders can be finalised and payments made.

Enquirer's Details

(the person making the enquiry)

Full Name:

Your Email)

Tel no including country code:

Alternative contact person email and telephone number:

Full Physical address including your state/province and country:

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The Recipient's Details

(the person who will get the Robohand)

Full Name

Age

Email

Tel no including country code:

Alternative contact person email and telephone number:

Full Physical address including your state/province and country:

Which product would you like to purchase?
 Robohand Robofinger Roboarm

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Does the recipient have any fingers? If so how many? Partial / Full?
 None Partial Full

Does the recipient have a thumb? Partial or Full?
 None Partial Full

Does the recipient have a palm?
 Yes No

Does the recipient have a functioning wrist (minimum 30 degree motion)?
 Yes No

Does the recipient have a functioning elbow (minimum 30 degree motion)?
 Yes No

Are there any sensitivity issues, areas of fragile skin, hypersensitivity or numbness?
 Yes No

If yes, please explain

Is the candidate’s hand/arm difference congenital or due to an accident?
 Congenital Accident

If accident please explain. (Example: burn, crush injury, amputation etc.)

Has the candidate had any hand surgeries?
If so, when was the last one and what is the overall outcome?

If the candidate has no hand, how much of the arm is remaining
from wrist to elbow and elbow to shoulder?

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Robohand

What are your expectations for Robohand?

How did you hear about Robohand?

Any additional comments:

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Photos

Please attach some close up photographs, back and front of both hands,
and if possible a video of both hands being turned over and back again.

Photo 1:

Photo 2:

Photo 3:

Photo 4:

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