Cranial Prothesis Quote Form

Divine Beauty Bar Cranial Prosthesis Custom Order Form

Once completed, your quote will be emailed to you within 24-48 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? (Veterans only. If not a veteran, write N/A).
- Photo/Video Consent: Divine Beauty Bar uses photos on all social media platform and marketing material for educational purposes. Occasionally, photos are sent to the VA Hospital, Insurance Company or medical offices, if requested.
- 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?
- Please note that any custom cranial prosthesis lengths greater than 14inches will take 40-60 days to arrive. Please note that any hair patterns other than straight hair will take 40-60 days 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 wait up to 2 months for your beautiful, Custom Cranial Prosthesis. Please enter the length of your Cranial Prosthesis below and/or hair pattern below. (ex. 20 inches loose wave);
- 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
- I agree and verbalized that Divine Beauty Bar has a 5 day warranty policy (90 day warranty for DMV Veterans only) once the prosthesis is received. Warranty is only for sizing issues. Divine Beauty Bar does not warrant color. By clicking this box, I am aware of the color I am choosing and if I do not like the color that I chose, I will pay additional to have the prosthesis dyed a different color by Divine Beauty or I will take the prosthesis elsewhere for a color change. Divine Beauty Bar does not warrant color. Standard colors, medical appropriate colors, are #1 (Black), #2 Dark Brown, #4 Brown, Salt & Pepper, Red and #27 Blonde.
- Color
- Hair Length(18in max for DMV Veterans)
  Hair Texture (Pixies, Braided/Locs, Straight, Body Wave, Loose Wave, Deep Curly, Yaki Straight, Kinky Straight. If you do not say Kinky or Yaki Straight, you will receive standard silky texture)
- Parting (Left, Right, Center, Bangs?)
- Cap Construction: Full Swiss Lace Cap, Silk Top, Monofilament, 100% Handtied, 100% Polyurethane Medical Cap, Monofilament with Polyurethane, Wefted Cap with Lace and Silicone Strips, 13x6 Frontal, 13 x4 Frontal, or 5x5 Closure Wefted Cap?
- Lace Type/Color?
- Hair Type(Human or Synthetic)
- Hairline Style:(Pre-plucked, Widow's Peak, Natural)
- Density?
- Provide a picture of your desired look and pictures of your Hair Loss. 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, bands or Silicone Strips? Please mention here:
- Signature: By signing or giving verbal consent, I acknowledge that the selections above accurately reflect my preferences for the Cranial Prosthesis. I understand that any changes must be approved prior to fulfillment. Orders may be changed or canceled within 48 hours of placement. Orders cannot be changed after the 48-hour window. Cranial Prosthesis exchanges or returns must be requested within 5 calendar days of delivery and acceptance, if the unit has not been altered, cut or tampered with. Changes once the order is delievered will result in a Change Fee.
- Should be Empty:

Divine Beauty Bar Cranial Prosthesis Custom Order Form