How to Apply

To be considered for wig customization, please download, print and complete the Recipient Application and take to your physician for Medical Verification. Please fill out the form completely without any modifications or alterations. Alterations to the form, including but not limited to crossed out content, handwritten clarifications, or overwritten copy will render the form void. Once the form is completed, return the form via Fax to 1-844-891-1384. We will contact you once the form is reviewed to begin your consultation and customization process.

This form is the required first step and no applications will be considered without this form completed in its entirety and a physician signature for the Medical Verification.

Download Application

Please note that a government issued identification is required at the initial consultation.