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TRUE by K. Nicole® | Specialty DME Provider | Cranial Prosthesis Solutions
Thank you for your interest in TRUE by K. Nicole®. We provide medical-grade cranial prostheses and medical wig solutions designed to support individuals experiencing hair loss.

This form allows you to connect with our Care Team so we can better understand your needs, assess whether our services are the right fit, and guide you through next steps with clarity, compassion, and clinical integrity.
✨ 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*
Preferred Contact Method
Care Needs & Support
What type of hair replacement support are you seeking?
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.
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Do you have any concerns, allergies, scalp sensitivities, or specific preferences that we should be aware of?
Is there anything important about comfort, wear, or daily maintenance that you’d like us to know? Example: lightweight feel, minimal daily styling, low manipulation
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.
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.
How do you plan to pay?
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