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Application For Hair Replacement
To qualify as a Hair Replacement Recipient, the recipeint must:

1) Be under the age of 21 (Need proof of Date of Birth by fax (734) 379-8983 or mail . Example: Birth Certificate, Driver's Licence or School Student I.D.)
2) Be experiencing hair loss due to a documented medical condition diagnosed by their physician.
Fill out the Online Request for Hair Replacement Form or print the pdf form, fill it out and send it to us, then we will contact you about your hair replacement needs.
If you have any questions about applying for Hair Replacement please give us a call or send us an email with your questions.

We look forward to helping with your Hair Replacement.
Printable Hair Replacement Request Form > > >

Recipient Information

First Name:
Last Name:
Gender:
 Birth Date:
Parents First Name:
 ParentsLast Name:
OR 
Contact Person
 Relation
Mailing Address
 City
State
 Zip Code
Phone
 EMail
Hair Diagnosis:
 
Referring Salon (if applicable)

Referred By
Salon Name
Street Address
 City
State
 Zip Code
Phone
 EMail

NOTES