Client Intake Form for Cranial Prosthesis 🩺

Client Intake Form for Cranial Prosthesis 🩺

Please fill out all required fields accurately. You will need your insurance information available to complete your intake form.
Client Information
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
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Insurance Information
Primary Insurance Provider
Primary Insurance Member ID
Primary Insurance Group Number
Primary Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insurance State
Do you have Secondary Insurance?
Secondary Insurance Provider
Secondary Insurance Member ID
Secondary Insurance Group Number
Secondary Insurance Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Insurance State
Medical Information
Diagnosis/Medical Condition
Treating Physician Name
Treating Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Treating Physician Address
Are you currently undergoing treatment?
If yes, please specify treatment type and duration
Hair Loss Details
Type of Hair Loss

Other
Cause of Hair Loss
Duration of Hair Loss (months/years)
Current Hair Loss Pattern
Prosthesis Preferences
Preferred Hair Color
Preferred Hair Length
Preferred Hair Texture
Preferred Base Type
Additional Preferences or Notes
How Did You Hear About Us?
Please select how you heard about us

Other
Consent and Agreements
Photo Consent: I consent to the use of my photos for the following purposes (choose one):
Client Signature
Print Name
Date

MonthDayYear
Date
Should be Empty:

Client Intake Form for Cranial Prosthesis 🩺

Client Information

Insurance Information

Medical Information

Hair Loss Details

Prosthesis Preferences

How Did You Hear About Us?

Consent and Agreements