New Client Intake form

Full Name*

First NameLast Name

Date of Birth

Date

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Delivery Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

ChemotherapyAlopeciaTrichotillomaniaOther (please specify)

YesNo

YesNoI need assistance

Upload Prescription Document

Upload Your Insurance Information

Preferred wig style*

Preferred wig color

Preferred cap size (if known)

Additional Comments or Special Requests

YesNo

Provider Name*

Provider Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about us?

HIPAA Privacy and Consent Details*

By signing below, you acknowledge that you have read and understood the HIPAA privacy practices and consent to the use and disclosure of your protected health information as described.

Jaye Deluxe Medical Hair Solutions is committed to protecting your privacy and complying with the Health Insurance Portability and Accountability Act (HIPAA). This consent form authorizes us to access, use, and disclose your medical information for the purpose of providing you with medical wig services and related care.

Your information will be handled with the utmost confidentiality and only shared with authorized personnel involved in your treatment and care. You have the right to revoke this consent at any time by contacting us in writing, except to the extent that action has already been taken based on this consent.

If you have any questions about how your information is used or your rights under HIPAA, please contact Jaye Deluxe Medical Hair Solutions. Your trust is important to us, and we appreciate the opportunity to serve you.

Signature*

New Client Intake form

Provider Information

HIPAA Privacy Authorization & Consent