New Client Intake Form
Hairbyhim Hair Loss & Restoration Palace Cranial Prosthetics
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Last Four of SOCIAL SECURITY NUMBER
Age/ Date of Birth
*
Have you been diagnosed with a medical condition that causes hair loss?*
Yes
No
If yes, please list your condition(s): (Alopecia Areata, Chemotherapy, Trichotillomania, etc.)
Do you have a prescription from your doctor for a cranial prothesis?
Yes
No
I need help obtaining one
Please Upload Prescription
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Physician's Name & Office Info (if available):
Insurance Provider:
Member ID / Policy Number:
Do you have out-of-network benefits?
Upload a copy of your insurance card (front & back)
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Have you ever worn a medical wig or cranial prosthesis before?*
Yes
No
Preferred Wig Type:
Glueless Unit
Adhesive Unit
Undecided
Type a question
Which type of pixie unit are you interested in( color, length, texture etc.)
Any allergies or sensitivities (e.g. adhesives, materials)?*
Please upload 1-2 clear photos of your current hair/scalp (top & front view): (used to assist with customizing your wig fit.)
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Preferred contact method:
Call
Text
Email
Best Day/Time for a consultation: (e.g. Mornings, Afternoons, Weekends, etc.)
How did you hear about us?
Please Select
Facebook
Instagram
Google
Gender
*
Male
Female
Other
How long have you been experiencing hair loss?
*
Which areas are affected by hair loss?
*
Scalp - Top
Scalp - Sides
Scalp - Back
Eyebrows
Beard/Facial Hair
Other
Have you tried any treatments for hair loss? If yes, please specify.
Do you have any known allergies?
Are you currently taking any medications? Please list them.
Please share any additional information or concerns.
HIPAA Privacy Acknowledgment & Consent HAIRBYHIM HAIR LOSS/RESTORATION PALACE Cranial Prosthetics – Client Intake Form HIPAA Notice of Privacy Practices & Authorization I acknowledge that HAIRBYHIM HAIR LOSS/RESTORATION PALACE Cranial Prosthetics may collect, store, and use my protected health information (PHI) for the purposes of evaluation, consultation, treatment planning, provision of cranial prosthesis (medical wigs), insurance billing, reimbursement assistance, and related healthcare operations. Protected health information may include, but is not limited to: Medical diagnoses related to hair loss. Physician documentation or prescriptionsInsurance informationPhotographs of the scalp or head (when applicable)Treatment notes and consultation records HAIRBYHIM HAIR LOSS/RESTORATION PALACE Cranial Prosthetics is committed to maintaining the privacy and security of my health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). My information will not be disclosed to unauthorized individuals or entities without my written consent, except as permitted or required by law, including but not limited to insurance carriers, healthcare providers, or billing partners involved in my care. I understand that: I have the right to request access to my records. I may request corrections to my health information. I may revoke this authorization in writing at any time, except where action has already been taken based on this consent.By signing below, I acknowledge that I have read and understand this notice and consent to the use and disclosure of my protected health information as described above. I have read and understood the HIPPA language provided*
Yes
Signature
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