Wig Program Eligibility Form

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.

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.

Wigs can either be shipped to you free-of-charge or you can arrange to pick them up from Germantown.

For questions about the Wig Boutique or other West Cancer Foundation programs please contact Vivian Tyler, vtyler@westcancerfoundation.org or 901-922-6781.

Step 1 of 3 - Your information

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PARTNERS

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