Client Intake Form

Tell Us More About Your Hair Loss

Helping us understand your specific needs for a tailored cranial prosthesis solution.
Full Legal Name

First NameMiddle NameLast Name
Date of Birth

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Insurance & Medical Details
Primary Insurance Provider Name
Insurance Subscriber / Policy ID Number
Group Number (if applicable)
Policyholder Name

First NameLast Name
Policyholder Date of Birth

MonthDayYear
Is this hair loss related to a diagnosed medical condition or treatment?
Type of Hair Loss / Diagnosis Code (ICD-10 if known)
If Other, please specify
Ordering / Prescribing Physician's Name & Clinic
Physician Phone Number & NPI (if available)
Do you have a written Prescription / Order for a Cranial Prosthesis?
Upload Doctor's Prescription / Medical Documentation

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Service & Product Selection
What type of cranial prosthesis or wig service are you seeking?
Preferred Payment / Coverage Method
Conditional Logic & Uploads
Would you like us to send a pre-qualification link directly to your mobile number?
Identity Verification
Driver's License - Front

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Driver's License - Back

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Insurance Card - Front

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Insurance Card - Back

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HIPAA Consent & Release Signature
I authorize Pretty Girl Extensions LLC to verify my insurance coverage and submit claims on my behalf.
Should be Empty:

Tell Us More About Your Hair Loss