Application For Hair Replacement

To qualify as a Hair Replacement Recipient, the recipeint must:

Be under the age of 21 (Need proof of Date of Birth by fax (734) 379-8983 or mail . Example: Birth Certificate, Driver's Licence or School Student I.D.)
Be experiencing hair loss due to a documented medical condition diagnosed by their physician.
Fill out the Online Request for Hair Replacement Form or print the pdf form, fill it out and send it to us, then we will contact you about your hair replacement needs.
Please Submit Birth Certificate and Diagnosis on letterhead from Doctor or Hospital with your application.

If you have any questions about applying for Hair Replacement please give us a call or send us an email with your questions.

We look forward to helping with your Hair Replacement.

Printable Hair Replacement Request Form

Recipient Information

First Name

Last Name

Gender

Birth Date

Parents First Name

Parents Last Name

Contact Person

Relation

Mailing Address

City

State

Zip Code

Phone

Hair Diagnosis

Referring Salon (if applicable)

Referred By

Salon Name

Street Address

City

State

Zip Code

Phone

NOTES



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