Cranial Prosthesis Consultation Intake Form

Cranial Prosthesis Consultation Intake Form

Thank you for scheduling your consultation. This brief form helps us make the most of our time together. Your responses are kept confidential.
Client Information
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
About Your Hair Loss Experience
Are you currently experiencing hair loss related to a medical or health condition?
If yes, please share the general cause (example: chemotherapy, alopecia, autoimmune condition, etc.)
Have you previously worn a cranial prosthesis or medical wig?
Preferences
Preferred hair length, color, or texture (if known):
Ex: 14", Body Wave, 1B, Straight
Will this prosthesis be worn daily or occasionally?
Any known allergies or sensitivities (adhesives, materials, etc.)?
Logistics
Preferred contact method?
Best general availability for consultations
Ex: Weekday Afternoons
How did you hear about Legacei Crowns?
Should be Empty: