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.
- 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?
- 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)?
- 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 14-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💙
- Please note that any custom cranial prosthesis lengths greater than Straight 14 inches will take up to 45-60 days to be completed. By entering a length longer than 14 inches OR a wave pattern other than straight (deep curly/wet and wavy), you are are confirming that you agree to wait 45-60 days to receive your custom Cranial Prosthesis. Please lease 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 (body wave, deep wave, straight, etc)
- Parting (Left, Right, Center, Bangs?)
- Provide a picture of your desired look and pictures of your Hair Loss, if applicable. Upload image(s) below.:
  
  Cancelof
- Are there any additional features, request or concerns that you wish to add which have not been mentioned above, such as adding combs or a particular cap construction? Please mention here:
- Signature
- Should be Empty:

Divine Beauty Bar Cranial Prosthesis Custom Order Form