Form

New Client Intake Form

Halo Of Hope Wigs•Medical Wig/Cranial Prosthesis/Durable Medical Equipment
Name

Last Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you been diagnosed with a medical condition that causes hair loss?
If yes, please list your condition(s): (Alopecia Areata, Chemotheraphy, Trichotillomania, etc.)
Do you have a prescription from your doctor for a cranial prosthesis?
Please Upload Prescription

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Physician's Name & Office Information (If available)
Insurance Provider
Do you have out-of-network benefits?
Member ID / Policy Number
Have you ever worn a medical wig/cranial prosthesis?
Any allergies or sensitivities (e.g. adhesive, lace materials, latex, etc.)
Upload 1-2 Clear Photos of Your Current Scalp
(Top & Front View)
(USED TO ASSIST WITH CUSTOMIZING YOUR WIG FIT)
File Upload

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Upload a Copy of Your Insurance Card & Government Issued ID
(FRONT & BACK)
File Upload

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HIPAA Privacy Authorization & Consent

By signing this form, I acknowledge and understand that HALO OF HOPE WIGS may collect, use, and disclose my personal health information (PHI) for the purpose of providing medical wig services, insurance verification, reimbursement assistance, consultations, and related business operations.

I authorize HALO OF HOPE WIGS to share my protected health information with physicians, insurance companies, medical offices, and third-party vendors as necessary to facilitate care and billing.

I understand that my information will be maintained in a secure manner in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy laws. I acknowledge that I have the right to request access to my records, request corrections, and revoke this authorization in writing at any time.

I understand that revoking this authorization will not affect any actions already taken based on prior consent.

I certify that the information provided is accurate and complete to the best of my knowledge.
Signature
Should be Empty:

New Client Intake Form