Medical Wig Intake Form

MEDICAL Wig INTAKE Form

PLEASE DO NOT SKIP SIGNATURE PAGE- if not complete we will discard entire submission. This form is for Medical unit inquiries ONLY. Please fill out in its entirety.
Name*

First NameLast Name
Your Date of Birth*

MonthDayYear
Date
Gender:

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Are you a Veteran*

YesNo
Health Insurance Plan Name:*
Health Insurance ID Number?*
Health Insurance Subscriber Name:
Turn the Card over - Give the Provider Services Phone Number?
Sometimes we cannot make it out on the picture.
Relationship to Subscriber:
Self, Spouse, Parent, or Child
If you have a secondary Health Insurance please list name here with ID Number:
Referring Doctor Name:*
Referring Doctor's Address & Phone Number:*
Referring Doctor’s NPI number?*
It is on the prescription
Have you been diagnosed with a medical condition that causes hair loss?*

YesNo
If yes, please list your condition(s): (Alopecia Areata, Chemotherapy, Trichotillomania, etc.)*
Have you ever worn a medical wig or cranial prosthesis before?*

YesNo
Hair length, color & Texture Preference:(e.g. 14" body wave, 1B, straight, etc.)*
Preferred Wig Type:*

Glueless UnitLace Front UnitFull Lace Unit
Any allergies or sensitivities (e.g. adhesives, materials)?*
These Items are needed:

Please upload these items
Do you have a prescription from your doctor for a cranial prothesis?*

YesNoI need help obtaining one
If you are requesting Insurance to pay or Reimburse your Unit- Please email a picture of Doctor's Prescription and Insurance card (front & back) to info@dddaughters.com

I will email a photo of my prescription and insurance card front and back
If you are requesting Insurance to pay or Reimburse your Unit- Please upload Doctor's Prescription

Cancelof
If you are requesting Insurance to pay or Reimburse your Unit- Please upload a picture of Insurance card (front & back) *

Please make sure I can read phone numbers and ID numbers
Cancelof
Upload your ID/ Drivers License Picture

Cancelof
Preferred contact method:*

CallTextEmail
How did you hear about us?*
Did a Doctor refer you? If yes, please share their name, address and phone number.
🔒 HIPAA Privacy Policy & Acknowledgment
D.D. Daughters Lace Wig Beautique respects your privacy and protects your personal health information as required by HIPAA. Information collected from you will only be used for treatment, payment, and insurance processing purposes.We will not share your information without your written consent except as required by law. By signing below, you acknowledge that you have received, read, and understand our privacy policy.*
🩹 Assignment of Benefits Form
I hereby assign all medical and durable medical equipment benefits, including major medical benefits, to which I am entitled. I authorize and direct my insurance carrier(s)—including Medicare, private insurance, and any other health or medical plan—to issue payment directly to D.D. Daughters Lace Wig Beautique for services rendered.I understand that I am financially responsible for any balance not covered by my insurance. This assignment will remain in effect until revoked by me in writing.I authorize D.D. Daughters Lace Wig Beautique to release any information necessary to my insurance carrier(s) to process my claim. I understand that fees are due and payable at the time services are rendered unless prior arrangements have been made.*
💳 Financial Responsibility Agreement
I understand that I am responsible for payment of all services rendered by D.D. Daughters Lace Wig Beautique, including those not covered by insurance.Payment is due at the time of service unless otherwise arranged. I acknowledge that insurance coverage for cranial prosthesis or medical wig units may vary, and I am responsible for any non-covered costs. I understand that missed appointments without 24-hour notice may incur a cancellation fee. By signing below, I confirm that I have read and agree to the financial terms outlined above.*
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL Wig INTAKE Form

These Items are needed:

🔒 HIPAA Privacy Policy & Acknowledgment

🩹 Assignment of Benefits Form

💳 Financial Responsibility Agreement