New Client Intake Form

  • New Client Intake Form

    Our intake form is the first step in beginning your medical wig (cranial prosthesis) journey. This form allows us to gather important information about your hair loss condition, medical history, and insurance coverage so we can properly assist you. Please complete the form in full and upload any requested documents, including your prescription and insurance details. The more accurate and detailed your responses are, the smoother and faster we can move through the verification and approval process. All information submitted is kept confidential and handled in compliance with HIPAA guidelines. Processing Timeline Within 24–48 hours: A specialist will review your information and begin the insurance verification process.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Have you been diagnosed with a medical condition that causes hair loss?*
  • Do you have a prescription from your doctor for a cranial prothesis?
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  • Browse Files
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  • Browse Files
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  • Have you ever worn a medical wig or cranial prosthesis before?
  • Preferred Wig Type:
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  • Preferred contact method:*

  • HIPAA Privacy Acknowledgment & Consent
    Crowns For Queens Medical Hair Restoration – Client Intake Form

    HIPAA Notice of Privacy Practices & Authorization

    I acknowledge that Crowns For Queens Medical Hair Restoration 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 prescriptions
    Insurance information
    Photographs of the scalp or head (when applicable)
    Treatment notes and consultation records
    Crowns For Queens Medical Hair Restoration 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.

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