What type of hair loss to you have: (Alopecia, Lupus, Cancer)*

When did you notice you were experiencing hair loss*

Have you seen a doctor about your hair loss? What type of hair loss did they diagnose you with*

What are you doing now to help regrow your hair?*

I wear protective hair styles such as*

I get hair treatment such as*

I shaved my hair completely off*

I am currently wearing natural hair*

I am currently doing nothing, seeking professional advice from*

Do you wear wigs, if so, how often?*

What type of wigs do you wear?*

Have you ever purchased a medical wig using health insurance?*

If yes, when was the last time you used insurance for a wig purchase? MM/DD/YYYY*

Do you need this wig for a special occasion*

How many wigs are you needing to purchase*

Insurance Company Name*

Policy Number*

Physician Name*

Physician Number or Email*

Client Contact Information Number*

Client Contact Information Email*