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Hair & Hope Recipient Application
Illinois, Indiana, Iowa, Kentucky, Minnesota, Missouri, Wisconsin residents only
. Patients in the defined geography may apply to discuss possible assistance with the cost of renting cold caps or using scalp cooling machines at clinics. Hair & Hope also offers support through mentorship if needed.
Please fill out the form and we will contact you about cold cap grants and support as soon as possible.
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Full Name
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Cell phone
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Email
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Zip code:
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Diagnosis (example: Breast Cancer Triple Negative, stage 2)
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Treatment Center, City, State
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What is your estimated start date of chemotherapy?
(If you are unsure at this point, write that.)
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How did you hear about Hair & Hope?
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Anything else you need to let know? Feel free to use this space.
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