Patient's Web Form - Coils To Locs

Name *

First

Last

Email *

Hospital Name

Hospital City and State

Name of the hospital's cancer center boutique/retail store (if known).

Are you a patient or hospital representative? *

How did you hear about Coils to Locs? *

Do you have any feedback about your personal medical wig or hair loss journey, that you'd like to share? (Patients)

If you are a hospital clinician, cancer center retail store representative, or a patient advocate, it would be helpful to know why you are interested in coily curly medical wigs and/or if you have had any difficulty finding these types of wigs for your patients.