Client Intake Form

Client Intake Form

Please complete this secure form to begin your virtual cranial prosthesis consultation. All information is confidential and required for insurance claim submission.
HIPAA Notice of Privacy Practices

Please review the HIPAA Notice of Privacy Practices carefully. Your privacy is important to us. By acknowledging below, you confirm that you have received, read, and understood this notice. For more information, visit https://www.hhs.gov/hipaa/for-individuals/privacy-notice/index.html.
Personal Information

Please provide your contact details.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medical Information

Details about your hair loss diagnosis and treating physician.
Diagnosis related to hair loss (e.g., alopecia, chemotherapy)*
Treating Physician's Full Name*

First NameLast Name
Physician's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Physician's Practice/Facility Name*
Insurance Information

Enter your insurance details for claim submission.
Primary Insurance Provider*
Policy Holder's Name*

First NameLast Name
Member ID / Policy Number*
Group Number (if applicable)
Insurance Customer Service Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secure Document Uploads

Upload required documents. All files are securely stored.
Upload prescription from your physician*

Cancelof
Upload letter of medical necessity*

Cancelof
Upload insurance card (front)*

Cancelof
Upload insurance card (back)*

Cancelof
Third-Party Billing Authorization

Authorize the release of your medical and insurance information to our designated billing specialist for insurance claim submission.
I agree and authorize release of my information for billing purposes.
Signature – Billing Authorization*

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Date – Billing Authorization*

MonthDayYear
Date
Financial Responsibility Statement

Please review and acknowledge your financial responsibility.
I acknowledge and accept financial responsibility.
Signature – Financial Responsibility*

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Date – Financial Responsibility*

MonthDayYear
Date
Sales and Hygiene Policy

Review our policy regarding cranial prosthesis sales and consultation fees.
I acknowledge and accept the sales and hygiene policy.
Signature – Sales and Hygiene Policy*

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Date – Sales and Hygiene Policy*

MonthDayYear
Date
PhoneEmailText Message
HIPAA Privacy Notice Acknowledgment

Please acknowledge the HIPAA privacy notice, which informs you about your privacy rights and how your information will be protected.
Date and Time of HIPAA Notice Acknowledgment*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Client Intake Form

HIPAA Notice of Privacy Practices

Personal Information

Medical Information

Insurance Information

Secure Document Uploads

Third-Party Billing Authorization

Financial Responsibility Statement

Sales and Hygiene Policy

HIPAA Privacy Notice Acknowledgment