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Customized Cranial Prothesis Quote
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Last 4 of SSN (Only Veterans. Not a veteran, write n/a)
Have you worn a wig before? If so, are they human hair or synthetic wigs? (Allergy to adhesive or glue?)
What method do you use to install your wigs? (Wig grip/Band, Adhesive/glue, Tape)? How do you remove them?
What inch would you like your unit to be? What pattern would you like your unit to be? Any length longer than 14 inches takes anywhere from 40-60 days to arrive. Also, any pattern other than straight takes 40-60 days to arrive.
Circumference __________________
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 ________________
Parting (Left, Right, Center, Bangs)_______
13x6 Frontal, 13x4 Frontal, 5x5 Closure, Full Lace? (Glueless, select 5x5 closure) _________________
Lace Type/Color ___________________
Hair Preference (Brazilian, Malaysian, etc.,) _________________________________
Provide a picture of desired look and pictures of hair loss.
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Any additional information, such as adding combs or silicone strips, write here.
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