Custom Medical Wig Interest Form

This form helps us understand your needs so we can recommend the most supportive option for you. There is no obligation, and pricing is always discussed with care and transparency.

First name

Last name

Email

Phone

Preferred Method of Contact

Phone

Email

Text

Timing

How would you describe your current scalp comfort needs?

I need something very consistent and gentle

I feel fairly flexible

I’m not sure yet

Texture & Style

Level of Customization

Which feels most important right now?

Something supportive and wearable soon

A long-term everyday solution

A fully personalized, highly customized build

Product or Servicing

Are you looking for:

A new custom unit

Servicing for an existing wig

Not sure yet

Support Preference

How would you like us to approach support?

I prefer to purchase the unit only

I’m open to optional 3-, 6-, or 12-month support

I’d like guidance on what makes sense

We Want To Hear From You:

Is there anything else you’d like us to know about your situation or goals?

Get Personalized Guidance

No pressure. No obligation. Just clarity.