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Trust Tiana Medical Wigs

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Client Information

Full Name

Date of Birth

Phone Number:

Email Address

Address

Emergency Contact

Name

Relationship

Phone Number

Medical Information (Confidential – HIPAA Protected)

Do you have any current medical conditions?

Yes No

If yes, please list

Are you currently undergoing any treatments (chemotherapy, radiation, etc.)?

Yes No

Do you have any scalp sensitivities, allergies, or skin conditions?

Yes No

If yes, please describe

Are you taking any medications that may affect your hair or skin?

Yes No

Service Goals

Checkbox

Medical Wig Consultation Custom Wig Fitting Cranial Prosthesis Services Beauty / Salon Services Other:

Consent & Privacy Acknowledgement

Client Signature

Date:

Provider Signature

Date:

condation

I acknowledge that the information provided is true to the best of my knowledge. I understand that my health information will be kept confidential in compliance with HIPAA and only shared with authorized personnel directly involved in my care or services.

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