Hair Peace Foundation Patient Application

Important Notice: While email consultations are free, please note that virtual and in-person consultations are billed at standard rates. Submitting this form is for qualifying for pro-bono work—it does not guarantee free services. We will review your application and inform you of your eligibility.

Personal Information

First Name*

Last Name*

Email*

Phone Number*

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Age*

Gender*

Occupation

Employment Status

Medical History

Have you been diagnosed with any medical conditions by a healthcare professional?

Yes

What medical conditions have you had or currently have?*

Please list any medical conditions you've had in the past or are currently experiencing.

If any, what medical treatments, therapies, or procedures have you undergone in the past?

What were the results/outcomes of your treatments?

Financial Information

What is your annual income?*

Please attach supporting documents (e.g., pay stubs, tax returns) for verification purposes.*

Addditional Information

What would you like us to know about your condition?

Please provide any details about your condition, circumstances, or motivations for seeking care through the Hair Peace Foundation's pro-bono program.

I am committed to attending all scheduled appointments and following the treatment recommendations provided by the Hair Peace Foundation.