Lynn's Cranial Prosthetics
NEW CLIENT INTAKE FORM
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Last Four Of Social Security Number
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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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Choose a file
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Physician's Name & Office Info (if available):
Meeting 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
Hair length, color & Texture Preference:(e.g. 14" body wave, 1B, straight, 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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Drag and drop files here
Choose a file
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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
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