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 qoute 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)? Would you like combs in your wig?
Circumfrence
Front Hairline to Nape .
Ear to Ear Over Forehead
Temple to Temple
Ear to Ear over top of head field.
Temple to Temple over Back of Head
Nape Length
Density Color
Length Hair Pattern
Parting (Left, Right, Center, Bangs?)If you are not using lace at the front or monofilament, your only option is bangs.
What is your time limit? Please note that a custom, Cranial Prosthesis typically takes 3-4 months to arrive.
Custom Cranial Prosthesis Options:

Option 1: Arrives less than 30 days. Each hair is individually hand tied, creating the appearance of natural growth. There is no "track," no machine wefting, therefore the Cranial Prosthesis is durable with minimal to no shedding or tangling! For a natural hair line, lace and/or monofilament is used at the front of the Prosthesis. Available in Straight, Loose Wave and Body Wave. Longest Length 20inches. Deep curly is not available. Please choose Option 2 for Deep Curly, Afro, Burgundy, Ombre or any Prosthesis longer than 20 inches. 30 Day Warranty, if there are no alterations made to the wig.Option 2: Arrives within 3 months (most common construction lace at the front and 1/8 interchains afterwards to allow air to flow. Interchains can be made bigger, if there is a special cream/oil/interjections your doctor use. This will allow you to use those special iteams without having to remove your Prosthesis). This construction is called Ventilation. Your wig will be ventilated strand by strand. There is no "track" (weft) and provides a versatile and natural look! If preferred, we can add Polyurethane or Silicone material for a Non-Slip touch, however this material can only be used on individuals with less than 2 inches of bio hair on their head as it adheres by using your natural body heat! All sales are final. No warranty on this option.Do you prefer a lace closure? Recommend 5x5 or 6x6 closure, especially for beginners)Do you prefer a lace frontal?Please ship once completed or...I will arrive and pay $100 installation fee at Divine Beauty Bar (4201 Cypress Creek Parkway Houston, Texas 77068) or...I am a US Veteran and would like a Complimentary Install
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? Please mention here:
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Divine Beauty Bar Cranial Prosthesis Custom Order Form