Cranial Prosthesis Intake Form
Complete this intake form to help us understand your needs for a cranial prosthesis and prepare for your visit or consultation.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Preferred Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Other
Medical and Hair Loss History
Reason for Cranial Prosthesis Need
*
Primary Diagnosis or Condition
*
Onset Date of Hair Loss
 -
Month
 -
Day
Year
Date
Duration of Hair Loss
Areas of Hair Loss / Affected Scalp
*
Frontal
Crown
Top/Vertex
Sides
Back
Entire Scalp
Other
Prior Treatments or Procedures Related to Hair Loss
Scalp Sensitivity, Allergies, or Skin Concerns
Scalp tenderness
Itching
Rash
Open sores
Skin irritation
Known adhesive sensitivity
Known material sensitivity
Other
Prosthesis Preferences and Fit Details
Prosthesis Type or Style Preference
*
Please Select
Full Cap
Partial Prosthesis
Hair Integration System
Frontal Piece
Other
Hair Color Preference
*
Hair Texture / Curl Pattern
Please Select
Straight
Wavy
Curly
Coily
Custom Match
Other
Density Preference
Please Select
Light
Medium
Heavy
Custom Match
Other
Cap / Base Preference
Please Select
Lace
Polyurethane
Silicone
Monofilament
Skin Base
Not Sure
Other
Custom Match to Existing Hair
*
Yes
No
Sizing, Measurement, and Special Fit / Comfort Notes
Appointment and Logistics
Preferred Appointment Date and Time
Insurance, Billing, and Documentation
Insurance Carrier Name
Member / Policy Holder Name
First Name
Middle Name
Last Name
Policy Type
Please Select
Individual
Family
Employer-Sponsored
Medicare
Medicaid
Other
Supporting Documents or Reference Photos
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