B'LAFLAIRE · VETERAN SERVICES

VA Program

Veteran Cranial Prosthesis Intake

A dedicated program for eligible Veterans seeking a custom cranial prosthesis for medically related hair loss with VA authorization.

For Eligible Veterans

VA authorization may be required before services can be provided. Complete the intake below so we can better understand your needs and where you are in the VA authorization process.

01 · THE PROGRAM

Hair With Purpose.

The B'LAFLAIRE VA Program is designed to support Veterans experiencing medically related hair loss who may qualify for a cranial prosthesis through the Department of Veterans Affairs.

Our intake process helps us better understand your hair-loss needs, preferred style, current VA authorization status and the next steps required to move forward.

The Process

A simple three-step process created to help Veterans understand what comes next.

Submit Intake

Complete the VA Program intake form with your contact information, hair-loss details and current authorization status.

Review

Your information will be reviewed to better understand your current stage and determine what additional information may be needed.

Next Steps

Eligible clients can receive guidance regarding consultation, authorization and cranial prosthesis selection.

Veteran Intake

VA Program Application

Please provide the information below so our team can better understand your needs, determine where you are in the VA authorization process and assist you with the appropriate next steps.

Contact Information

First Name *

Last Name *

Email Address *

Phone Number *

Hair Loss Details

What Is The Primary Cause Of Your Hair Loss? *

Tell Us More About Your Hair Loss

VA Authorization

What Is Your Current VA Authorization Status? *

VA Medical Center

VA Provider / Care Team

Cranial Prosthesis Preferences

Preferred Hair Texture

Preferred Length

What Is Your Primary Goal For Your Cranial Prosthesis?

Additional Information

Anything Else We Should Know?

I understand that submitting this intake form does not guarantee VA eligibility, authorization, approval, reimbursement or payment for services.

B'LAFLAIRE is not affiliated with or operated by the U.S. Department of Veterans Affairs. Eligibility, authorization and coverage are determined by the appropriate VA provider and VA healthcare system. Submission of this intake form does not guarantee authorization, approval, reimbursement or payment.