MEDICAL Wig INTAKE Form
This form is for Medical unit inquiries ONLY. Please fill out in its entirety.
Name
*
First Name
Last Name
Your Date of Birth
*
 -
Month
 -
Day
Year
Date
Gender:
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Health Insurance Plan Name:
*
Health Insurance ID Number?
*
Health Insurance Subscriber Name:
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:
*
Have you been diagnosed with a medical condition that causes hair loss?
*
Yes
No
If yes, please list your condition(s): (Alopecia Areata, Chemotherapy, Trichotillomania, etc.)
*
Have you ever worn a medical wig or cranial prosthesis before?
*
Yes
No
Hair length, color & Texture Preference:(e.g. 14" body wave, 1B, straight, etc.)
*
Preferred Wig Type:
*
Glueless Unit
Lace Front Unit
Full 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?
*
Yes
No
I need help obtaining one
If you are requesting Insurance to pay or Reimburse your Unit- Please upload a Doctor's Prescription
*
Browse Files
Drag and drop files here
Choose a file
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of
Upload pictures of your Hairloss Front of Head - Required for Insurance Claims
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload pictures of your Hairloss Back of Head - Required for Insurance Claims
*
Browse Files
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Choose a file
Cancel
of
Upload Front & Back of Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Driver's License ID Card
*
Browse Files
Drag and drop files here
Choose a file
Name on ID must match your health insurance card
Cancel
of
Preferred contact method:
*
Call
Text
Email
How did you hear about us?
*
Please Select
Tiktok
Facebook
Google search
The News
Instagram
Friend
Relatives
Other
🔒 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.
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🩹 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.
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Date
*
 -
Month
 -
Day
Year
Date
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