Wigs for Veterans Program
100% No Cost to the Veteran!
Are you a Veteran struggling with thinning edges, shedding, patches or complete Alopecia (Totalis)?
Yes
No
Are you frustrated with finding a stylist specializing in Cranial "Wig" Prosthesis?
Yes
No
Are you experiencing Alopecia due to Stress, PTSD, Depression, Age, Lupus, Cancer, Genetics, Military Uniforms/Hats and much more?
Yes
No
Diagnosis causing Hair Loss?
What is your #1 Goal for your Cranial "Wig" Prosthesis?
What are your biggest frustration with wearing Wigs?
If you could wave a magic wand, how would you solve it?
What is your ideal Cranial Prosthesis (style, length, color, density, etc)?
Are you in need of additional Prosthetics such as, Mastectomy Bras and Breast Prosthetics?
Yes
No
Name
*
First Name
Last Name
Gender?
Your Contact Number
*
Please provide a phone number so we can contact!
Last 4 SSN?
*
This is to confirm that you are a veteran!
Email
*
example@example.com
Branch of Service?
How did you hear about us?
*
Name and Number of the VA Hospital you receive services from?
*
A member from Divine Beauty Bar will continue you within 24-48 hours!
Submit
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