Patient Intake Form

Confidential · Please complete all fields · Return to Crown Restore upon arrival

Welcome to Crown Restore. This form helps us prepare your consultation, verify your insurance benefits, and ensure your fitting is personalized to your needs. All information is kept strictly confidential.

Personal Information

Full Legal Name

Preferred Name (if different)

Date of Birth

Age

Sex Assigned at Birth

Home Address

Mailing Address (if different)

Primary Phone

Alternate Phone

Email Address

Preferred Contact Method

Preferred Contact Time

Emergency Contact

Emergency Contact Name

Relationship

Phone

Insurance Information

Please bring your insurance card to your appointment. We will verify your benefits prior to your fitting.

Insurance Company / Plan Name

Member ID / Policy Number

Group Number

Insurance Phone Number

Primary Insured Name (if not patient)

Primary Insured Date of Birth

Do you have secondary insurance? Yes No

Secondary Insurance Company (if applicable)

Secondary Member ID / Policy Number

Medical History & Hair Loss Information

For Clinical Use · Please complete all applicable fields

Referring Physician

Referring Physician Name

Specialty

Practice / Hospital Name

Phone

Fax

Primary Diagnosis

Primary ICD-10 Diagnosis Code

Secondary Code (if applicable)

Diagnosis Description / Condition

Cause of Hair Loss — Check all that apply

Medication Name (if medication-induced)

Other cause (if applicable)

Hair Loss History

When did hair loss begin?

Rate of loss

Current stage

Is the hair loss expected to be: Temporary (treatment-related) Permanent Uncertain at this time

Expected duration of hair loss (if known)

Are you currently undergoing treatment?

Current Medications

List all current medications (name & dosage)

Scalp & Sensitivity

Scalp sensitivity or tenderness Open sores, lesions, or active scalp conditions Scalp itching or inflammation Skin allergies (latex, adhesives, dyes) Scalp scarring or irregular shape No known scalp sensitivities

Allergy details or additional scalp notes

Hair Profile & Style Preferences

Help us find your perfect fit · All textures 1A – 4C

Your Natural Hair Texture

Select the type that best describes your natural hair before hair loss began.

1A–1C Straight Fine to coarse, completely straight with no curl pattern 2A–2C Wavy Loose to defined S-waves, medium body and movement 3A–3C Curly Defined spiral or corkscrew curls with volume 4A–4C Coily Tight coils to kinky-curly, high density and shrinkage

Hair & Style Preferences

Preferred Hair Length

Preferred Hair Color

Color Preference

Material Preference

Cap Construction Preference

Lifestyle & Wear Considerations

Active lifestyle / frequent exercise Work in a professional / clinical setting Prefer low-maintenance styling Comfortable with heat styling Will wear daily (full-time wear) Occasional / part-time wear Sensitive to heat / warm environments Concerned about secure fit during activity

Additional style notes or requests

How Did You Hear About Us?

Patient Consent & Authorization

By signing below, I authorize Crown Restore (a medical wig program by Crown & Texture) to:
· Contact my insurance provider to verify benefits and submit claims on my behalf
· Communicate with my referring physician or care team as needed
· Retain this intake form and related documents in my confidential patient record

I understand that Crown Restore will make every effort to verify my coverage prior to my appointment and will inform me of any out-of-pocket costs in advance. I also understand that insurance reimbursement is not guaranteed and varies by plan.

Patient Signature

Sign here with mouse or finger

Date

Parent / Guardian Signature (if patient is a minor)

Sign here with mouse or finger

Relationship to Patient

Emailinfo@crowntexturehair.com

Phone+1 (404) 449-6744

HoursMon–Fri 9am–5pm · Sat by appt