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Patient Form

Hairs 2 U Free Wig Donation Program will provide you a wig, hat or scarf free of charge if you are going through chemotherapy or a illness that causes hair loss if you are uninsured for a wig. Our goal is to help make this time of healing as stress free as possible.

Your hospital or social worker must fill out this form for eligibility. This form must be completed prior to your coming in.

Please note: If you arrive to your consultation without this form, without exception, we will be unable to proceed.

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Patient information                                                                                                                   Please print or type                 

Name                                                                                                                                                                                                                            Address                                                                                                                                                                                                                       

City and State                                                                                         Zip Code:                                                                                              

Phone Number                                                                                        Cell Number                                                                                         

Email Address                                                                                                                                                                                                          

Signature                                                                                                 Date                                                                                                         

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Agency Information

Agency Name                                                                                                                                                                                                         

Agency Address                                                                                                                                                                                                        City and State                                                                                           Zip Code                                                                                              Social Worker Name                                                                                                                                                                                              

Social Worker Phone Number                                                                                                                                                                          

Social Worker Signature                                                                                                                                                                                      

Comments                                                                                                                                                                                                                  

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For Office Use Only          Hairs 2 U Wig Bank                                                                   

760 S. 4th St        Philadelphia Pa 19147      215/922/2119                                           

Employee Name                                                                                                                                                                                                     

Wig Name                                                                                                  Wig Color                                                                                             

Wig Value                                                                                                                                                                                                                   

Patients Signature (sign in store)                                                                                                                                                                    

Additional Comments:

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