Use this form to apply for a hair replacement system from Wigs for Kids.
| Please print, fill out and mail this completed form to: Wigs for Kids
Executive Club Building
21330 Center Ridge Road, #26
Rocky River, Ohio 44116 Fax: 440-333-3840 Or if questions call: 440.333.4433 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. That they 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 salon) you have contacted that 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 please contact us. 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.
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| 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 | |
Request a Hairpiece 