Thank you for inquiring with The Clique Spa & Beauty Studio.
This form helps us understand your hair loss journey, your insurance options, and what you need so we can recommend the best medical-grade solution for you.

Please complete all sections so we can properly review your case before your consultation.

Personal Information

First Name *

Last Name

Phone *

Email *

Address *

Street Address

City

State

Country

Postal Code

Medical Hair Loss Information

Have you been diagnosed by a physician/dermatologist? *

Yes

No

Physician or Dermatologist Name:

Facility / Office:
Phone Number:

When did your hair loss begin? *

Within the last 3 months

3–12 months ago

1–3 years ago

3+ years ago

List any current medications you’re taking: *

Prescription & Insurance Information

Insurance:

Provider Name:
Policy Holder Name:
Member ID:
Group Number:

Do you have a prescription for a cranial prosthesis? *

Yes

No

Pending

I need instructions on how to get one

Upload Your Prescription (if available):

Upload photos of your insurance card: Front & Back

Have you verified coverage with your insurance company?

Yes

No

Unsure

Daily Lifestyle & Comfort Needs

Have you worn a wig before? *

Yes

No

Your preferred hair length and texture: *

Reference chart below

Your preferred hair color:

Example: Jet black, honey blonde, platinum, copper etc...

Support Needs & Concerns

What are your biggest concerns about this process?

Please Explain

Is there anything you want me to know before your consultation?

Please Explain

Medical Photos & Data Privacy Consent

By checking below, you authorize The Clique Beauty & Hair Restoration Center to:

Take and store clinical photos for documentation and insurance submission.

Securely store your medical information and records for your case.

Contact your provider and insurance for verification if necessary.

Photos will not be used for marketing without your separate written consent.

Agreements & Consent

By submitting this form, you agree to receive text messages and phone calls from The Clique Beauty & Hair Restoration Center. You acknowledge that some calls may be automated, pre-recorded, or use an AI voice to assist with scheduling, updates, and service information. You also consent to receive marketing communications, promotions, and updates related to our services. Message and data rates may apply. You may opt out of messages or calls at any time by replying STOP or contacting us directly.

I consent to The Clique Beauty & Hair Restoration Center reviewing my medical and insurance information to determine eligibility.

You consent to be contacted regarding your form submission and next steps.

I acknowledge that all information provided is accurate to the best of my knowledge.

Today's Date: *

Signature *

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