• Cranial Prosthesis Medical Intake – Creating a Better You

  • Date
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Have you been medically diagnosed with hair loss?
  • Type a question
  • Date of Diagnosis
     - -
  • Currently recieving treatment

  • Describe current or past treatments

  • Hair Loss History
  • Hair Loss Considered

  • Scalp conditions (itching, tenderness, scarring)

  • Allergies
  • Seeking Insurance Reimbursement

  • Insurance Notice: Cranial prostheses may be covered by insurance when prescribed for medical hair loss. Creating a Better You provides documentation; coverage and reimbursement are determined solely by your insurance provider.

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  • Date Signed
     - -

  • Creating a Better You – Cranial Prosthesis Consent & Service Agreement

    I understand that a cranial prosthesis is a custom medical device created specifically for my medical hair loss condition.

    I acknowledge that Creating a Better You does not guarantee insurance reimbursement and that coverage decisions are made solely by my insurance provider.

    I understand that once production has begun, cranial prostheses are non-refundable due to their custom nature.

  • Date (required)
     - -
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