Submit Info for a Cranial Prosthesis

Please provide us with the following information and we will reach out to you via phone to get further information and see if we can accept your insurance. Please make sure your have your dermatologist submit a request to the medical device department to approve your prescription and need for cranial prosthesis. 

*Name

*Date of Birth

*City and State

*Your Phone Number AND email

*Insurance Company or VA Hospital 

*Provider phone number listed on the back of your card or your VA Hospital phone number

*Member ID

*Last 4 of your SSN (Veterans only)

*Type of hair loss

*Diagnosis causing hair loss (Cancer, Alopecia, Lupus, Age, Stress, Genetics, etc)