A 501(c)3 NonProfit Organization

Wigs

Pantene Expressions

SKU H400 Category Wig

Inventory available while supplies last. Please fill out the application in its entirety.

All wigs are average size and can be adjusted to fit.

You must upload your prescription for a wig to meet compliance.

Our wigs are for the uninsured or underinsured.

Color	Clear

Name*
First Last
Email*
Phone*
Recipient Age*
Please enter a number from 0 to 130.
County*
Annual Income*
- Under $20,000
- Over $20,000
Ethnicity*
Type of Hair Loss*
- Chemotheraphy
- Radiation
Type of Cancer*
Oncologist / Physician
Name
First Last
Phone*
Prescription for Wig*
Max. file size: 300 MB.
You must upload your prescription for a wig to meet compliance.
Terms & Conditions*
By checking this box you are agreeing that you have been medically diagnosed with cancer and all information you have provided is true and accurate.

Color	Auburn (R30), Chocolate Copper (R630H), Dark Chocolate (R6), Dark Cinnamon (R8), Ginger Blonde (R25), Glazed Hazelnut (R829S+), Golden Walnut R825, Golden Wheat (R1488), Honey Ginger (R1425), Midnight Brown (R4), Pecan Brown (R12+)

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