Patient Forms

Below, you will find certain forms that may be required for you to download and complete. There are also some brochures you may find useful. For more information, please contact Victory Orthotics & Prosthetics.



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Bracing for the Upper and Lower Limbs

Orthotic Intake Form


Shoes and/or Shoe Inserts

Pedorthic Intake Form


Back and Neck Bracing

Spinal Intake Form

Limbs For Life

Limbs For Life is a national organization who covers the cost of a basic prosthesis. The application is based on income level. The final page of the application also must be completed by a prosthetist. For more information go to

Apply Today

Amputee Coalition

The Amputee Coalition provides financial assistance for prosthetics, durable medical equipment, and other assistive devices. Financial assistance options can be viewed below.

Financial Assistance Options


For more information go to

Apply Today

Medicare Supplement - Medigap

Medicare supplement plans aim to help cover what Medicare does not. It covers some deductibles, co-insurance, co-payments, and other costs not covered by Medicare Parts A & B.

For more information go to or call 855-309-7322 to speak with an agent.

NOTE: You cannot buy a Medigap policy if you have a Medicare Advantage Plan unless you first disenroll from the Medicare Advantage policy.


For more information go to

To see if you qualify, go to

Mending Limbs

For more information go to

Apply Today