Cranial Prosthesis Intake Form

Cranial Prosthesis Intake Form

At no cost to Veterans! Other insurance providers may cover between 80 to 100% of the total cost.
Personal Information:
Full Name:*

First NameLast Name
Birth Date:*

MonthDayYear
Phone Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender:*
Employer:*
Occupation:
E-mail:*
Marital Status:*
Spouse's Name:
Spouse's Occupation:
Spouse's Employer:
Emergency Contact:*
Emergency Contact Phone Number:*
Primary Care Provider:*
Primary Care Provider Phone Number:*
Primary Care Provider Email:*
Medical Information:
Reason for Cranial Prosthesis? (e.g., medical condition, injury): *
6. Physician's Name: *
6. 7. Physician's Contact Information: *
Phone:
6. 7. Physician's Contact Information: *
Email:
Insurance Information:
Do you plan to use insurance for this service?*

YesNo
6. Insurance Provider Name: *
6. Policy Number: *
If using the Veteran Affairs: Last 4 of S.S.N.
6. Policy Holder's Name:
If different from above.
6. Relationship to Policy Holder:
6. Branch of Service:
If using the Veteran Affairs.
Cranial Prosthesis Preference:
Have you ever worn a cranial prosthesis before?*

YesNo
If yes, please describe any preferences or issues you had with your previous prosthesis:
6. Desired color: *
If known:
6. Desired style: *
If known:
6. Desired length: *
If known:
6. Desired curl pattern: *
If known:
Any additional customization or features you're looking for?
Additional Information:
How did you hear about our studio?*

ReferralWebsiteAdvertismentOther
Photo Release:
I hereby grant Unconscious Beaute' Studio permission to use my photographs taken during my appointments for promotional, advertising, and online media purposes.
Please enter your name below to confirm your agreement for our salon treatments.
Patient's Signature:*
Date:*

MonthDayYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
HIPPA Release:
I understand that Unconscious Beaute' Studio adheres to the Health Insurance Portability and Accountability Act (HIPAA) and will keep my personal health information confidential. I hereby authorize Unconscious Beaute' Studio to use or disclose my health information in connection with the provision, coordination, or management of my care, including for the purposes of diagnosis, consultation, treatment, and referral to other providers of health care.
Please enter your name below to confirm your agreement for our salon treatments.
Patient's Signature:*
Date:*

MonthDayYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Consent and Authorization:
I authorize Unconscious Beaute' Studio to contact my physician and insurance provider for the necessary information and documentation related to my cranial prosthesis. I understand that the provision of services is based on the availability of products and the approval of my insurance.
Please enter your name below to confirm your agreement for our salon treatments.
Patient's Signature:*
Date:*

MonthDayYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Thank you for reaching out! A representative from Unconscious Beaute' Studio will respond to your inquiry within 24-48 hours. Stay connected with us for all your beauty needs!
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Cranial Prosthesis Intake Form

Personal Information:

Medical Information:

Insurance Information:

Cranial Prosthesis Preference:

Additional Information:

Photo Release:

HIPPA Release:

Consent and Authorization: