Cranial Prothesis client intake form

Divine Beauty Bar Cranial Prosthesis Custom Order Form

Once completed, your quote will be emailed to you within 24 hours. If you are a Veteran, your quote will be emailed to the Veteran Affairs Hospital.

Client Overview
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Country CodeArea CodePhone Number
E-mail*
example@example.com
Last 4 of SSN? (Veterans only. If not a veteran, write N/A).
Have you worn a wig before? If so, do you typically wear Human Hair or Synthetic Wigs? Any allergies (allergic to lace? Allergic to adhesive/glue?)
How do you install your wigs (Wig Grip/Band, Adhesive/Glue, Tape)? How do you remove them?
STYLIST PLEASE READ TO VETERANS: Hello, Veteran Divas! The VA Hospital provides 1-2 Cranial Prostheses per year, depending on your local VA. Think of this as your "Annual, once a year, Medical Wig"—customized to meet your everyday medical needs. Please remember that Cranial Prostheses are prescribed for medical reasons, not cosmetic. The 30-day warranty covers sizing issues only; it does not apply to color. Once the lace is cut, the warranty is voided. As required by the VA, your Cranial Prosthesis will be provided within 30 days in a standard color, standard style (pixie cuts, straight hair only, or straight hair with curls), and glueless (closure wig). Thank you for your service and for allowing us to service you💙*

I agree and verbalize understanding of theN/A; I am not a Veteran
Please note that any custom cranial prosthesis lengths greater than 14 will take 3-4 months to arrive. Please note that any hair patterns other than straight hair will take 3-4 months to arrive. By entering a length longer than 14 inches OR a wave pattern other than straight (deep curly/wet and wavy), you are choosing to go against the VA Cranial Prosthesis Policy, and your Cranial Prosthesis will not be warranted by Divine Beauty Bar. Please enter the length of your Cranial Prosthesis below and/or hair pattern below.
Circumfrence
Front Hairline to Nape .
Ear to Ear Over Forehead
Temple to Temple
Ear to Ear over top of head
Temple to Temple over Back of Head
Nape Length
Color
Length
Hair Pattern (pixie, straight or straight with curls added)
Parting (Left, Right, Center, Bangs?)
Provide a picture of your desired look and pictures of your Hair Loss. Upload image(s) below.:

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Are there any additional features, request or concerns that you wish to add which have not been mentioned above, such as adding combs? Please mention here:
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Divine Beauty Bar Cranial Prosthesis Custom Order Form