Cranial Prosthesis Client Intake Form

Cranial Prosthesis Client Intake Form
Please complete this form to help us understand your needs for a cranial prosthesis (medical wig) service.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
What is the primary reason for your hair loss?
Other
Describe your current scalp and hair condition.
Do you have any allergies or sensitivities (especially to adhesives, materials, or hair products)?
If yes, please specify your allergies or sensitivities.
Have you previously used a cranial prosthesis or wig?
What style, color, and length do you prefer for your cranial prosthesis?
Preferred appointment date and time
Should be Empty: