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HELPING CHILDREN LOOK THEMSELVES AND LIVE THEIR LIVES


Application Form

 

 

 

 

 

Please complete this form to apply for assistance from Wigs for Kids.

Wigs for Kids is a private nonprofit organization providing hair replacement systems for eligible children 18 years of age and younger who have hair loss as a result of chemotherapy, radiation treatments, alopecia, burns, or other medical circumstances.

We are also working to educate the medical community and the public on the issues, challenges and available options for children with hair loss.  For more information on how you can help or for literature for distribution in your office, school or location, please call 440.333.4433.   Thank You!

Please print, complete and mail this form to:

Wigs for Kids - APPLICATION FORM
24231 Center Ridge Road
Westlake, Ohio 44145

FAX: 440-835-1084

Or call us at: 440.333.4433 IF YOU HAVE QUESTIONS

All information must be complete prior to sending or approval will be delayed.

 

 

How did you hear about Wigs for Kids?:

 
SECTION ONE: Patient Hairpiece Request Form
Childs Name:  
Guardian Name: Male                 Female
Age  Date of birth:
Address  
City  
State/Province  
Zip or Postal Code  
Country  
Email:  
Telephone:  
School/Grade:  
Comments:  
   
SECTION TWO:  Medical Information
Reason for Hair Loss:  
Are you undergoing medical treatment? Yes        No
If yes, what type of treatment?  
Have you already experienced hair loss? Yes         No
Name of Physician:  
Hospital/Office location:  
   
SECTION THREE: Insurance Information
Do you have medical insurance? Yes No
If yes, name of insurance company, COMPLETE ADDRESS AND PHONE - COPY FRONT AND BACK OF CARD)  
Policy No.  
Does your insurance cover prosthetic devices.  Yes No
Do you have a prescription for a cranial prothesis? Please submit a copy with application. Yes No
   
SECTION FOUR: Referral Information (ALL INFO MUST BE COMPLETE)
Name of Hospital /Organization:  

Telephone:

  

EMAIL:

  
Doctor       Nurse     Social Worker       Other
Address:  
City  
State/Province  
Zip  

Signature of Representative

By signing this application you are stating that there is a financial need on behalf of the recipient and family.  That this family would otherwise not be able to afford payment of this prosthetic device.

  

SECTION FIVE: Salon Information

Please include the contact name, salon name, address and telephone number of a local HAIR REPLACEMENT CENTER IN YOUR AREA.  If you are unsure look in the Yellow Pages under Hair Replacement.  We ask that you assist us in contacting them to ask if they will work with you to provide measurements and final cutting and styling of the hair piece once it has been created. The salon will need a tape measure.  Wigs for Kids will send a detailed instruction form for measurements.  If you need assistance with finding a hair replacement center please contact us at 440-333-4433.  The accuracy of the measurements are CRITICAL, as-well-as the cutting of the wig.

Salon Name:

Address:

City, State, Zip:

Contact Person:

Phone:                                                  Fax:

Email:                                              Website:

email and website are critical for continued communication with the salon for WFK Updates and Information.  Thank You.

___ They are a Hair Replacement Center  

____ Not a Hair Replacement Center

____ Salon License Number ___________________________________
FOR OFFICE USE:  
Approved by:  
Date received:  

Measurements/Photo/Sample Rcv'd:

  

Date to OP:

  
Shipped:  
 
Retail value of hair replacement package:  $
Donation to Wigs for Kids by patient: $
HRCR:  Approved  
PD