B’LAFLAIRÉ • VA CRANIAL PROSTHESIS VETERANS PROGRAM • MEDICAL HAIR

VA Cranial Prosthesis Order Form

Please complete every selection carefully after your doctor approves your cranial prosthesis order.

Create Your Custom Fit

SECTION 01

Client Information

First Name *

Last Name *

Shipping Address *

City

State

Zip Code

Phone

Email *

SECTION 02

45-Day Acknowledgment

B’Laflairé has up to 45 days to complete and deliver the custom cranial prosthesis.

I acknowledge and agree to the completion and delivery timeframe.

SECTION 03

Photo / Video Consent

Authorize only the uses you approve. Appropriate documentation may be shared with the VA, insurers, or healthcare providers when requested.

I authorize photographs.

I authorize video recordings.

I authorize appropriate documentation sharing.

SECTION 04

Head Measurements

Use a soft measuring tape and enter all measurements in inches.

1. Circumference

2. Front to Back

3. Ear to Ear Over Forehead

4. Temple to Temple

5. Ear to Ear Over Top

6. Temple to Temple Over Back

7. Width of Neck

SECTION 05

Color Options

Hair Color

SECTION 06

Hair Type

Select Hair Type

SECTION 07

Hair Length

Select Hair Length

SECTION 08

Hair Texture

Select Hair Texture

SECTION 09

Hair Density

Select Hair Density

SECTION 10

Cap Construction

Wig Type

Cap Construction

SECTION 11

Preferred Style

Preferred Parting

Preferred Styling

SECTION 12

Upload Your Photos

Paste a secure shareable link containing your inspiration photos and clear photos of the areas experiencing hair loss.

Shareable Photo Link

SECTION 13

Additional Requests

Include any preferences for combs, adjustable bands, elastic bands, silicone strips, scalp sensitivities, security features, or other special accommodations.

Requests or Concerns

SECTION 14

Schedule Your Video Consultation

Choose your preferred weekday date and time. All times are shown in Central Time and require confirmation from B’Laflairé.

Your selected date and time are appointment requests. Your call is not officially scheduled until you receive confirmation by email or text.

Preferred Date *

Preferred Time *

Call Method *

Best Phone Number *

Confirmation Email *

I understand this is an appointment request and is not scheduled until B’Laflairé confirms it.

SECTION 15

Final Acknowledgment

I confirm that my selections are accurate. Changes must be approved before fulfillment begins.

An order may be changed or canceled within 48 hours.

Exchange or return requests must be made within five calendar days of delivery. The cranial prosthesis must remain uncut, uncolored, unaltered, unworn, and untampered with.

Approved modifications requested after completion or delivery may require an additional modification fee.

I reviewed my selections and accept these terms.

SECTION 16

Client Signature

Sign inside the box using your finger, stylus, Apple Pencil, mouse, or trackpad.

Full Legal Name *

Signature Date *

Sign Here

VA Cranial Prosthesis Order Form

Client Information

45-Day Acknowledgment

Photo / Video Consent

Head Measurements

Color Options

Hair Type

Hair Length

Hair Texture

Hair Density

Cap Construction

Preferred Style

Upload Your Photos

Additional Requests

Schedule Your Video Consultation

Final Acknowledgment

Client Signature

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