Wig Form - West Cancer Foundation

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

How did you hear about us?

Before filling out the form, please ensure that you have shopped the online wig boutique and have determined which wig(s) you would like to request. You will be asked to input the wig number (ex. Blonde 101 or Red 106) from the wig boutique. Please note that we cannot guarantee the wig(s) you have chosen as we have limited quantities, however we will contact you with there are any problems with you order.

How many wigs are you requesting?(Required)

Which wig(s) are requesting? (ex. Blonde 101 or Brunette 200)(Required)

Do you want your wig(s) shipped to you or would you like to pick it up?(Required)

Ship to me

Arrange pick up from Germantown

The West Cancer Foundation Wig Boutique is intended for cancer patients who have lost or are losing their hair as a side effect of cancer treatment and cannot afford to purchase one. The following information is requested to help determine eligibility for the program to ensure that we are able to help as many people as we can.

Are you a cancer patient in active treatment?(Required)

Yes

No

Prefer Not to Say

Estimated Annual Household Income(Required)

Household Size (including you)(Required)

Do you have health insurance?(Required)

Yes

No

Prefer Not to Say

Name

This field is for validation purposes and should be left unchanged.