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.

Q. Can we use your comment, if appropriate, to highlight the challenges you or others have experienced in our marketing materials and/or on our website? (First and last initials would be used).

To ensure you are not a bot, please answer the math problem below. *

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