Patient Form

Hairs 2 U Wig Donation Program will provide you a wig, hat or scarf free of charge if you are going through chemotherapy or an illness that causes hair loss. 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 appointment and submitted on the scheduled appointment date.

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

Patient information                                                                                                                   Please print or type                 

Name                                                                                                                                                                                                                            Address                                                                                                                                                                                                                       

City and State                                                                                         Zip Code:                                                                                              

Phone Number                                                                                        Cell Number                                                                                         

Email Address                                                                                                                                                                                                          

Signature                                                                                                 Date                                                                                                         

Agency Information

Agency Name                                                                                                                                                                                                         

Agency Address                                                                                                                                                                                                        City and State                                                                                           Zip Code                                                                                              Social Worker Name                                                                                                                                                                                              

Social Worker Phone Number                                                                                                                                                                          

Social Worker Signature                                                                                                                                                                                      

Comments                                                                                                                                                                                                                  

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:

                                                                                                                                                                                                                                      

 

 

 

:

©Dejah Designs - dejahbryan@gmail.com

Created through Wix.