Contact Form
Name: First & Last
I am a (or the person I am inquiring for is)Male
Female
Birthdate (Day, Month and Year)
Street Address
City & State
Zip Code
Email Address:
Daytime Contact Phone Number
Evenng Contact Phone Number
Best time to callHours01
02
03
04
05
06
07
08
09
10
11
12
:
Minutes00
15
30
45
AM
PM
I am inquiring today about aFull Wig
Partial Wig
Toupee
Hair Piece
Topper
Hair Extensions
Bridal Up do
Children's Wig
A Wig for my Teenage Son or Daughter
Make a wig using my own hair.
I am interested inA followup phone call
Email Contact
In Salon Consultation
Phone Consultation
In home visit
In hospital visit
Making plans to visit a Wiggin Out Salon location
Check all that applyI have just began loosing my hair.
I have been experiencing hair loss for years
I have bald spots or a bald spot
I have severe thinning
I believe that my hair loss is from stress
My hair is falling out in clumps
I am going to begin chemotherapy soon.
I am not sure when I start chemotherapy
I am very distressed from my hair loss
I am not ready to wear a wig
I am ready to look at wigs.
I would like to look into wearing a hair piece
I am bald
No hair loss-Just want thicker or longer hair
I am almost bald
I have had bad experiences with wearing wigs
I have no experience wearing wigs
I am not sure about wearing a wig
I have been wearing wigs for years
I have experience wearing hair pieces
I have been diagnosed with Alopecia
I have hair loss from hair extensions
I am inquiring for a friend or family member
I am inquiring about making a wig using own hair
I am inquiring about Post Chemo hair re-attachment
I am inquiring about children's wigs
I am inquiring about hair extensions
I would like to learn more about my options
I am not sure why I am here. Please help.
Medications I am currently taking
Please state any surgurys in the past 5 years
Have you had in the last 5 years experienced childbirth?Yes
No
Miscarriage
Are you going to begin chemotherapy? If yes when do you start your treatments?
If you have alopecia, are you scheduled to have any type of treatments performed? If so, please decribe your treatments.
Please tell us who referred you to our website?
Are you eating healthy? On supplements? Please decribe your health regimen if you have one.
I will need a wig by the date below:
I really do not want to wait for a wig to be made for me. I am interested in seeing your pre-custom made wig selectionyes
no
I am not sure
Activities that I participate in. (Please check all that apply)Swimming
Sailing
Crusing
Volleyball
Scuba Diving/Snorkling
Diving
Gymnastics
Theater
Acting/TV/Motion Picture
Artist
Musician /studio/stage
Walking
Running
Biking
Yoga (regular)
Heated Yoga
Horseback riding
Wrestling
Social Events
Socializing
Boxing
Farm/Ranch Activity
Atv's
Motercycles (I wear a helmet)
Acrobats
I am not active
I am not active since my hair loss
My hair loss has not stopped my being active
I would like to engage in other activities soon
I have a wedding to attend in the near future
I have an important social event to attend
Just please help
Preferred Date for my appointment
Preferred TimeHours01
02
03
04
05
06
07
08
09
10
11
12
:
Minutes00
15
30
45
AM
PM
If your planning an in salon visit, please state which location you will be visitingThousand Oaks, Ventura County, CA
Newport Beach, Orange County, CA
Charlotte, NC, Mecklenburg County, CA
Do you live out of the area or out of state?Yes
No
Will you need a Wiggin Out Salon staff member to help you with plane and hotel reservations? Please state your needs.
Will you be cutting off your own hair to make a wig? Are you bringing in donated hair to make your wig? Please explain below:
