New Client Intake Form
Legacei Cranial Crowns
Client Details:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
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.)
*
Do you have a prescription from your doctor for a cranial prothesis?
*
Yes
No
I need help obtaining one
Physician's Name & Office Info (if available):
Insurance Provider:
*
Member ID / Policy Number:
*
Do you have out-of-network benefits?
Upload a copy of your insurance card (front & back)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload a copy of your license (front only)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Have you ever worn a medical wig or cranial prosthesis before?
*
Yes
No
Preferred Wig Type:
*
Lace Front
Full Lace
Glueless Unit
Closure Unit
Undecided
Hair length, color & Texture Preference:(e.g. 14" body wave, 1B, straight, etc.)
*
Any allergies or sensitivities (e.g. adhesives, materials)?
*
Please upload 1-2 clear photos of your current hair/scalp (top & front view): (used to assist with customizing your wig fit.)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preferred contact method:
*
Call
Text
Email
Best Day/Time for a consultation: (e.g. Mornings, Afternoons, Weekends, etc.)
*
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Feedback about us:
Suggestions if any for further improvement:
Will you be willing to recommend us?
Yes
No
Maybe
Please give reference of any two people whom you feel:
Full Name
Address
Contact Number
1
2
Submit
Should be Empty: