WIG RECIPIENT APPLICATION FORM - PH
HOW TO APPLY FOR A WIG PIECE
(As of January 3, 2019)

1. Check our criteria if you are eligible to apply for a wig.

To be eligible for a wig piece, the recipient needs to meet the following criteria:
1. Must be a resident citizen of the Philippines
2. Must be 25 years of age or younger (18 and below are given more priority)
3. Is experiencing hairloss like alopecia or as a result of therapies to fight cancer.
4. Is referred by a medical professional who signs and submits medical proof or prescription for need of wig piece.

2. Submit the Online Application
- If you/your child meet the above criteria, you may proceed on submitting the online form
to apply for a wig.
https://docs.google.com/forms/d/e/1FAIpQLSeDcDbgpfD_XZTWCVMSKCfEsFDu9NNWwgKDrZHkmrpXgN72tg/viewform

3. Wait for an email that confirms the receipt of application.
- As soon as the online application has been submitted, you will receive an email within 24
hours confirming the receipt of your application and providing the next steps in the
process.
- Check your inbox and spam for the email from “care@cutsagainstcancer.org ”. If you do
not see the email within 24 hours of the application submission, please send a message
to ______________, indicating “WIG RECIPIENT APPLICATION/Name/Age/Email
Address”. Example: WIG RECIPIENT APPLICATION/Maria
Clara/17/maria.clara@gmail.com
- As part of the next steps in the application process, as the email will outline, you need to
submit all the required documentation and pictures.
- Once we receive and verify the completeness of requirements, your application will be
reviewed, and you will be notified via email regarding the status of your application within
48 hours.
Email address *
PATIENT'S INFORMATION
Patient's First Name *
Your answer
Patient's Last Name *
Your answer
Gender *
Age *
Your answer
Birthday *
MM
/
DD
/
YYYY
Contact Number (or of guardian) *
Your answer
Residence Address *
Your answer
City/Province *
Your answer
Country *
Your answer
Average Monthly Household Income
MEDICAL HISTORY
Diagnosis *
Your answer
Stage *
Your answer
Date of Diagnosis *
MM
/
DD
/
YYYY
Attending Hospital *
Your answer
Attending Physician/Oncologist *
Your answer
Contact Number of Attending Physician/Oncologist *
Your answer
Current Treatment *
Your answer
Last Chemo Cycle *
Your answer
Attending Doctor/Physician's Prescription for need of wigs/Proof for need of wigs
Please send this requirement via email to care@cutsagainstcancer.org
IMMEDIATE GUARDIAN
Full Name *
Your answer
Relationship with the Patient *
Your answer
Contact Number *
Your answer
Email Address *
Your answer
Notes, comments or story you think we should know ?
Your answer
A copy of your responses will be emailed to the address you provided.
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