For applicants: Download or print this form and bring it to your physician to complete.

Lala's Wings 501(c)(3) Nonprofit · Elmhurst, IL

Document Medical Verification Form

Wig Assistance Program

Physician Medical Verification

To be completed by a licensed medical professional on behalf of the applicant. This form verifies the patient's eligibility for the Lala's Wings Wig Assistance Program and must accompany or follow the completed applicant application.

Dear Medical Provider, Thank you for supporting your patient in accessing this resource. Lala's Wings provides free wigs to cancer patients experiencing hair loss due to chemotherapy or radiation. This form is used solely to verify medical eligibility and will be kept confidential.

Please complete all fields, sign, and return this form to your patient or email it directly to us at lalaswings501@gmail.com.

Section 1

Patient Information

Patient Full Name

Date of Birth

Patient Mailing Address

City

State

Zip Code

Section 2

Medical Information

Cancer Diagnosis

Date of Diagnosis

Type of Treatment

Chemotherapy

Radiation

Immunotherapy

Other:

Treatment Status

Currently undergoing treatment

Scheduled to begin treatment

Recently completed treatment

Is the patient experiencing or expected to experience hair loss due to cancer treatment?

Yes

Additional Clinical Notes (Optional)

Section 3

Provider Information & Signature

Medical Provider Full Name

Title / Credentials (e.g. MD, DO, NP)

Medical Facility / Practice Name

Provider Phone Number

Facility Address

Provider Email (Optional)

By signing below, I confirm that the above information is accurate to the best of my knowledge and that this patient is under my care for the diagnosis and treatment described. I authorize Lala's Wings to use this information solely for the purpose of determining eligibility for the Wig Assistance Program.

Provider Signature

Date

Internal Use Only

Application Received Date

Reviewed By

Approval Status

Approved

Waitlist

Denied

Notes