MailPoet Page

Name *

First

Last

Birthday *

When is your birthday? (mm/dd/yyyy)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Email

Confirm Email

Medical Condition Type *

Cancer
Alopecia

What type of medical condition do you have? (Cancer or Alopecia)

Condition Specifics *

What type of cancer and/or alopecia do you have?

Treatment Location *

Where are you being treated? (i.e. Beth Israel, Dana-Farber, MD Anderson, St. Jude's, Johns Hopkins, Mayo Clinic)

Oncologist/Physician Name *

What is the name of your oncologist?

Have you ever worn a full lace wig before? *

Yes
No

Do you currently have a head covering? (Headwraps, wigs, hats, etc.) *

Yes
No

How would a premium lace wig from Ahead of Beauty help you? *

How did you learn about us? *

Required Documents *

Letter signed by oncologist/physician (wig prescription)

Please note applications will not be reviewed unless required documents are submitted.

Upload Letter/Prescription *

Please upload a prescription from your oncologist/physician for a wig/cranial prosthesis OR an official letter from your oncologist/physician stating that you are under his/her care and require a wig due to hair loss from ongoing treatment.

Prescription/letter must be addressed to the Ahead of Beauty and dated within 30 days of submission. Other forms will not be accepted and will delay your application approval process. (Allowed file extensions: .jpg, .jpeg, .doc, .pdf, .png)

Are you willing to submit Proof of Income in order to qualify for a free wig or are you planning to use insurance?

Yes, I can provide proof of income
No, I cannot provide proof of income
I plan on using insurance to cover the cost of the wig

Would you like to share your story? Testimonials help our non-profit grow and give hope to patients facing cancer. *

Yes, I would like to share my story after receiving my wig.
No, I am not interested.

We’re looking forward to hearing from you!

Interested in partnering with us?

Let us know!

Name *
First
Last
Email *
Phone *
Are you representing an Corporation/Organization? *
Yes
No
Corporation/Organization Name (if applicable)
How would you like to partner with Ahead of Beauty? *
Email