Cranial Prosthesis Client Intake Form

Gather a client's contact details, measurements, and style preferences for a custom cranial prosthesis (wig).

Use this template

Full Name

First Name

Last Name

Phone Number

Email

Please tell us your reason for getting a custom prosthesis

Have you worn a wig before?

What are your head measurements?

Will you provide your own bundles and closure?

What is your time limit?

What services are you interested in?

Custom Wig Wig Styling Wig Maintenance Consultation

Upload photos of your desired look

Max 10 MB per file

Please share any other information about your cranial prosthesis

Are there any additional features you'd like to add that haven't been mentioned above?

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