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
Executive Club Building
21330 Center Ridge Road, Suite 26
Rocky River, Ohio 44116 FAX: 440-333-3840 Or call us at: 440.333.4433 IF YOU HAVE QUESTIONS |
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SECTION ONE: Patient Hairpiece Request Form: PLEASE PRINT ALL INFORMATION |
Childs Name: Guardian's Name: | |
| Birth Date: | Male or Female |
| Age: | |
| Address | |
| City | |
| State/Province | |
| Zip or Postal Code | |
| Country | |
| Email: | |
| Telephone: | |
| School/Grade | |
| Comments: | |
Would you consider holding a Wigs for Kids Fundraiser? Would you be interested in corresponding with another recipient or hair donor? Yes or No Would you be willing to write a minimum of 3 thank you notes for us to send to donors who support our children? |
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| 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 To what extent? |
| Name of Physician: | |
| Hospital/Office location: | |
| Address, City, State, Zip | |
| SECTION THREE: Insurance Information (complete all) |
| Do you have medical insurance? | Yes No |
If yes, name of insurance company Insurance Company complete address and phone number | |
| Policy No. | |
Diagnosis Code: ________ Does your insurance policy cover prosthetic devices | Yes No |
| Do you have a prescription for a cranial prothesis? Please send if possible. | Yes No |
| | |
| SECTION FOUR: Referral Information - A REQUIREMENT |
Name of Hospital /Organization: | |
| Telephone: | |
Email Address: Referring Representative: | |
| CIRCLE: 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; that they would otherwise not afford to purchase a hair piece on their own. | X_________________________ |
Please let us know of a hair replacement salon in your area that would assist with head measurements as well as the final "cut-in" once the hair piece is created. We ask that they would have a private room. You can look at our salon listing on our site to see if there are any in your area. If you are local to NE Ohio, we will have you come to Jeffrey Pauls Salon in Rocky River. Local Hair Salon Contact: Phone: Address: Please send hair piece to: __ Home ___ Salon | |
Upon review and approval of this application we will be sending a packet of information to the address listed on the front of the application. We look forward to working with you!
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| For Office Use Only | |
| Approved by: | |
| Date received: | |
| Consultation date: | |
| Measurement/AAK sent: | |
| Order Date: | |
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| Retail value of hair replacement package: | $ |
| Donation to Wigs for Kids by patient: | $ |
| HRCR: Approved | |
| PD | |
Medical Information 