Wigs For Veterans Program
Servicing those who serviced us!
Are you a veteran struggling with thinning edges, shedding, patches or complete alopecia (totalis)?
Yes
No
are you struggling with finding a stylist that understand hair loss and cranial prosthesis?
Yes
No
are you experiencing hair loss due to stress, ptsd, military hats, depression, age, lupus, cancer, etc?
Yes
No
Diagnosis causing Alopecia?
what is your #1 goal for your cranial "wig" prosthesis?
What is your biggest frustration with wearing wigs?
if you could wave a magic wand, how would you solve it?
What is your ideal cranial prosthesis? (length, color, style, density)
Please list any additional prosthetics that you may need (Mastectomy bras, breast prosthetics, wheelchair, walker, diabetic shoes, back brace, nebulizer, etc)
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Last 4 of SSN
Branch of Service
Name and number of VA hospital where you receive services
please choose time and date for our master stylist to give you a call:
-
Month
-
Day
Year
Date
Submit
Should be Empty: