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.

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)? 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 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
Color
Hair Length
Hair Texture (Straight, Body Wave, Loose Wave, Deep Curly)
Parting (Left, Right, Center, Bangs?)
13x6 Frontal, 13 x4 Frontal, 5x5 Closure, Full Lace? (For a glueless fit, please select 5x5 Closure)
Lace Type/Color?(HD Lace available)
Hair Preferences(Brazilian, Malaysian, Burmese, Raw Cambodian, Raw Indian, Raw Vietnamese, Raw Laotion)
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, such as adding combs or Silicone Strips? Please mention here:
Signature

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Divine Beauty Bar Cranial Prosthesis Custom Order Form