Online Client Intake Packet
Below is a multi-step online form. There are 12 different sections and you must complete each section before moving on to the next. Make sure to complete the form, sign it, and submit it all in one sitting.
Do not complete packet using Safari or an iPhone. It will not submit correctly.
If you use Aetna as your primary insurance, you must also sign and upload (or mail) the signature forms that Aetna requires. Download the Aetna Signature forms on our Client Intake Packet Page.
Getting Started
This is a multi-step form that you'll need to complete to start the wig purchasing process.
You will receive a copy of the Compliance Assurance Notification and Customer Bill of Rights forms that are at the end of this form.
Before we start, we need a few documents from you. You can scan these files or take pictures and upload them.
- REQUIRED: Your Driver's License or Photo ID.
- REQUIRED: The front and back of your Insurance Card(s).
NOTE, upload copies of ALL INSURANCES, PRIMARY AND SECONDARY. We need a copy of your primary insurance even if it does not cover wigs.
Upload these files into the appropriate blocks below. If you are unable to upload the files, complete the Printable Client Intake packet.