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TRUE by K. Nicole® | Specialty DME Provider | Cranial Prosthesis Solutions
Begin Your Cranial Prosthesis Request

Thank you for your interest in beginning the cranial prosthesis process with TRUE by K. Nicole®.

This form allows our care team to gather your initial preferences and determine the best pathway for your care. You’ll have the opportunity to share the tier you would like to stay within, along with your desired style and any important details related to your request.

Once your form is submitted, our team will review your information and follow up with instructions to schedule your Cranial Prosthesis Consultation, where we will finalize your selections, take proper measurements, and review next steps for production.

We look forward to supporting you through this process.
✨ What Happens After You Submit This Form
• Complete this form with your contact information and care preferences
• Share inspiration photos or notes that help us understand your goals
• Indicate your preferred care tier and payment pathway
• Our Care Team will review your submission and contact you regarding next steps

Submitting this form does not initiate production. All services begin after a consultation and confirmation of payment method or insurance pathway.
⚠️ Care Coordination Notice
Submitting this form connects you with our Care Team but does not guarantee immediate appointment availability.

Consultations are scheduled based on clinical capacity and care alignment. Once availability opens, our team will reach out to guide you through scheduling and preparation.
CONTACT INFORMATION
Full Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Preferred Contact Method
Care Needs & Support
What type of hair replacement support are you seeking?
Which best describes your current hair loss experience?
This helps our Care Team understand your care needs. You are not required to provide a diagnosis.
What is your experience with wigs or cranial prosthetics?
Have you encountered any common issues with previous wigs or prosthetics?
Poor fit, lace lifting or unnatural hairline, cap discomfort or irritation, too hot or heavy, tangling or shedding, difficulty styling, longevity of the hair, etc.
Do you have any concerns, allergies, scalp sensitivities, or specific preferences that we should be aware of?
What is most important to you in your next cranial prosthesis?
Natural hairline, comfort lightweight cap, longevity of the hair, low maintenance, etc.
Upload a photo of the outcome or style you’re hoping to achieve?

This may be a general reference image. Exact materials, construction, and customization will be determined by our Care Team based on your care tier, wear needs, and medical considerations.
Cancelof
Do you currently know your head measurements?
If needed, our Care Team provides guidance during your consultation. Measurements are not required to submit this form. Detailed measurements and design decisions are completed during your consultation to ensure accuracy, comfort, and appropriate clinical support.
Care Pathway and Financial Coordination
Which care tier best aligns with your needs at this time?
Each care tier reflects differences in materials, construction, customization level, and longevity. Final recommendations are made during your consultation to ensure appropriate clinical support, comfort, and long-term wear.
Coverage and Payment Pathway
If you selected Insurance as a payment method, our team will send you a separate Insurance Verification Form. Completing this step ensures clarity regarding your insurance benefits.

We appreciate the opportunity to support you. A member of our Care Team will be in touch to guide you through next steps with clarity and care.

We look forward to connecting with you!
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Connect With Our Care Team

✨ What Happens After You Submit This Form

⚠️ Care Coordination Notice

CONTACT INFORMATION

Care Needs & Support

Care Pathway and Financial Coordination