Thank You For Choosing Forever Young!
Our mission is dedicated to restoring confidence by providing cranial prosthetics to veterans, cancer patients and individuals experiencing any form of medical related hair loss. Providing high quality medical wigs help us bridge the gap between healthcare and beauty!
Client Intake
Please take a few moments to complete the following forms. The information you provide helps our team understand your needs, verify insurance coverage, and create a customized experience for your hair restoration journey. Please complete all required fields marked with asterisk(*), upload ay requested documents (if applicable), and sign electronically where indicated.
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Last 4 Social Security Number:
*
Contact Information (Email)
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
Your medical information helps us verify eligibility for coverage and ensure your cranial prosthesis or related services meet medical requirements. All information shared is kept strictly confidential and protected in accordance with HIPPA privacy laws.
Diagnosis: (if applicable)
Would you like to be referred to a physician for diagnosis?
*
Yes
No
How long have you been experiencing medical related hair loss?
Are you currently undergoing chemotherapy or treatments?
Physician Name:
Physician Specialty:
Physician Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Physician Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Verification
Please provide your insurance information so we can verify coverage and benefits for your services. All information is confidential.
Insurance Provider:
*
Insurance Policy ID Number:
*
Group Number:
Plan Type:
Please Select
HMO
PPO
VA
MEDICAID
PRIVATE PAY
FSA
Upload a copy of your government issued ID, Front and Back of your medical insurance card, medical necessity letter (if applicable), and your diagnosis RX.
*
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Client Consent Forms
Please click to read and review our online consent forms:
Did you read and review our Consent Forms as shown above?
*
Yes
No
Do you agree to our Social Media Consent?
*
Please Select
Yes
No
Do you authorize Forever Young & Company to contact your insurance or medical provider?
*
Please Select
YES
NO
Schedule Your Consultation:
*
By initialing below, I acknowledge that I have read, understood, and agree to all terms, policies, and consents outlined above. I confirm that all information provided is true and accurate to the best of my knowledge.
Signature
*
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: