New Client Intake Form

Client Details:

Full Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Format: (000) 000-0000.

E-mail*

example@example.com

YesNo

If yes, please list your condition(s): (Alopecia Areata, Chemotherapy, Trichotillomania, etc.) *

YesNoI need help obtaining one

Please Upload Prescription

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)

YesNo

Glueless UnitClosure UnitUndecided

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.)

CallTextEmail

Best Day/Time for a consultation: (e.g. Mornings, Afternoons, Weekends, etc.)*

How did you hear about us?*

Please Specify

HIPAA Privacy Acknowledgment & Consent
Crown and Comfort Cranial Solutions – Client Intake Form

HIPAA Notice of Privacy Practices & Authorization

I acknowledge that Crown and Comfort Cranial Solutions 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
Crown and Comfort Cranial Solutions 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.

Signature*