Wigs for Veterans

Veteran Cranial Prosthesis Intake

For Eligible Veterans With VA Authorization
This intake form is for Veterans seeking a custom medical cranial prosthesis for medically related hair loss. Please provide the information below so our Clinical Care Team can better understand your needs, determine where you are in the VA authorization process, and assist with the appropriate next steps.
Hair Loss Details - What is the primary cause of your hair loss?
Please select the main reason for your hair loss, such as medical conditions, stress, or service-related causes.
What is the diagnosis causing your hair loss?
If you selected "Other" in the previous answer, you can elaborate here
What is your primary goal for your cranial prosthesis?
(Example: "Comfort, style, restoring confidence, ease of use")
What are your biggest frustrations with wearing wigs?
(Example: "Uncomfortable fit, unrealistic look, maintenance issues")
Please describe your preferred cranial prosthesis.
(Length, color, texture, density, style, or other preferences.)
Full Name:

First NameLast Name
Gender:
Phone Number:
"Please provide a phone number so we can contact you!"Format: (000) 000-0000.
Verify your Email
Branch of Service:
Please select the branch of service you are or were in.
Last 4 SSN:
This is for VA verification purposes
Which VA Medical Center or VA facility is managing your cranial prosthesis request?
Please provide the facility name and city/state. If you have a direct phone number, you may include it.
Name of VA Contact in the prosthetics department (if known):
This can help expedite the process.
Do you currently have a VA referral, authorization, or prescription for a cranial prosthesis?
Have you already received a consult/referral from your primary care doctor within the VA Hospital for a custom medical wig due to your hair loss condition.
Upload VA Authorization for 2026

Please provide your consult/referral from the VA.
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How did you hear about us?
Please let us know if you were referred by a VA case manager, prosthetics department, or found us through another source Google etc.
How did you hear about us?
Please let us know if you were referred by a VA case manager, prosthetics department, or found us through another source Google etc.
PLEASE NOTE: Veterans working with VA Prosthetics or Community Care may request Heavenly Tresses for cranial prosthesis services.
Schedule Your Veteran Cranial Prosthesis Consultation
Signature: By signing below, you confirm that the information provided in this intake form is accurate to the best of your knowledge and authorize Heavenly Tresses to use this information to assist with your cranial prosthesis inquiry and applicable VA coordination. Submission of this form does not guarantee VA eligibility, authorization, or coverage.
We are honored to support you on this journey. Your information will be kept confidential and secure. Once submitted, our team will reach out to discuss the available custom cranial prosthesis options and connect with your VA to begin the process.
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Veteran Cranial Prosthesis Intake