Cranial Prosthesis Intake Form | Crownz Heavenly Palace

First name

Last name

Address

Email

Phone

Birthday

Month

Day

Year

Are you a veteran? If yes, what is the last 4 of your SSN?

Have you worn a wig before?

Yes

No

What type of wig are you familiar with?

Synthetic

Human Hair

Both

Have you experienced any allergies while wearing a wig? If so, specify if the allergy is to lace, adhesive glue, etc.)

Have you been diagnosed with a medical condition that causes hair loss?

Yes

No

Please list your condition(s): (Alopecia, Trichotillomania, Chemotherapy/Radiation, Lupus, etc.)

Please Read: A prescription from a doctor or physician is required for a cranial prosthesis wig. A valid prescription is necessary to qualify for possible insurance coverage and to verify medical necessity for reimbursement.

I understand and I do have a prescription from a doctor or physician.

I understand, but I do not have a prescription from a doctor or physician.

Doctor/Physician's Name

Doctor/Physician's Number

Please upload prescription

Please Read: Crownz Heavenly Palace LLC is not in network with insurance plans. Clients pay out of pocket and receive a superbill to submit to their insurance for possible reimbursement. We assist with benefit but cannot guarantee coverage.

I understand and agree to these terms

I do not agree to these terms

Insurance Provider

Member ID/Policy Number

Upload a copy of the front and back of your insurance card and government-issued ID

VETERANS: For insurance coverage, cranial prostheses are lengths up to 14 inches and feature closures. Available textures include straight, body wave, and curly, with a standard natural color and style options of pixie, long straight, or long curly.

I understand and acknowledge these terms

Not Applicable, I am not a veteran

Please indicate whether you are a veteran requesting a custom cranial prosthesis wig that falls outside of VA guidelines or a non-veteran requesting a custom cranial prosthesis wig. In addition, please specify your desired length, texture, and style.

Provide an image of your desired look and provide a few images of your hair loss.

Additional information or requests:

I have read and completed this form in its entirety to the best of my ability.

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