Apply For Hair

Hair Replacement Requirements
To qualify as a Hair Replacement Recipient, the recipeint must:

  • Be under the age of 21 (Need proof of Date of Birth by fax (734) 379-8983 or mail . Example: Birth Certificate, Driver’s Licence or School Student I.D.)
  • Be experiencing hair loss due to a documented medical condition diagnosed by their physician.
  • Fill out the Online Request for Hair Replacement Form (below) or print the PDF Form, fill it out and send it to us, then we will contact you about your hair replacement needs.
  • Please submit application, birth certificate, doctor verification of diagnosis and a picture, if possible, with and with out hair so it can help us design the hair replacement. These pictures will not be shared and only CWHL will use them.

When the package is delivered to the home, salon, or hospital, a signature will be required.
If you have any questions about applying for Hair Replacement please give us a call or send us an email with your questions. We look forward to helping with your Hair Replacement.

  • Children With Hair Loss
    12776 Dixie Hwy
    South Rockwood, MI 48179
  • (734) 379 4400
Application For Hair Replacement

Click HERE to download the printable Hair Replacement Request PDF Application

If you prefer to apply online, and you meet all of the requirements listed above, please fill out the form below.

OR
Mailing Address
Referring Salon (if applicable)
Hair Replacement Specifics