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
City and State Zip Code:
Phone Number Cell Number
Agency Address City and State Zip Code Social Worker Name
Social Worker Phone Number
Social Worker Signature
For Office Use Only Hairs 2 U Wig Bank
760 S. 4th St Philadelphia Pa 19147 215/922/2119
Wig Name Wig Color
Patients Signature (sign in-store)