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For your privacy and protection, please do not include any medically sensitive or personal health information (such as diagnoses, treatment details, or medical history) in this form. Any medical-related details can be discussed safely during your consultation. This form helps us understand your preferences ahead of time so your consultation can be more comfortable, efficient, and personalized. Please answer as much or as little as you feel comfortable sharing and we will be in touch with you shortly.

Full Name

Phone

Preferred method of contact:

Call Text Email

Are you looking for a wig:

Immediately Within 2–4 weeks Just exploring options

Have you worn a wig or hair replacement before?

Yes No

What is the reason for hair loss?

Medical treatment Alopecia Thinning hair Other / Prefer not to say

Desired Length:

Preferred Texture:

Do you prefer:

Tone Preference:

Desired Color:

What is your cap size (learn how to measure your cap size)?

Do you prefer:

Lightweight / breathable cap Extra security Softest feel possible Not sure

How often do you plan to wear your wig?

Daily A few times a week Occasionally

Activity level while wearing:

Mostly low-activity Active / on-the-go

Desired maintenance level:

Low maintenance Willing to style Not sure

Are you working within a specific budget range?

Will you be using insurance or a medical prescription?

Yes No Not sure

Do you have reference photos or inspiration? (jpg, png, gif, pdf)

Is there anything else you’d like us to know before your consultation?

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