Medical Patient Application

Begin Your Access Application

Complete this form to apply for access to our Medical Hair Bank catalog. All applications are reviewed within 48 hours. Your medical information is kept strictly confidential.

1
Personal Info
2
Medical Details
3
Documentation
4
Preferences
5
Submit
Personal Information
Medical Information
Required Documentation
Upload Prescription or Medical Letter
PDF, JPG, PNG, or DOC · Max 10MB

A letter from your physician confirming medical hair loss and recommending a cranial prosthetic.

Upload Supporting Medical Records (Optional)
Diagnosis records, treatment summaries · Max 10MB
Upload Insurance Card — Front & Back
JPG or PNG · Max 10MB
Prosthetic Preferences
Patient Agreement

Applications are reviewed within 48 hours. You will receive a confirmation email at the address provided. We never share your medical information.

The House of Postiche
What Happens Next

Your Application Journey

From submission to your first fitting, we walk with you every step of the way.

1
Application Received You'll get a confirmation email within minutes of submitting.
2
Medical Review — 48 Hours Our team reviews your documentation and verifies eligibility.
3
Catalog Access Granted Approved patients receive private credentials to view the full catalog.
4
Select & Reserve Browse available units and reserve the one that fits your needs.
5
Custom Fitting & Delivery Your cranial prosthetic is prepared and delivered at community pricing.

Your Privacy is Protected. All medical documentation is encrypted, never shared with third parties, and retained only as long as necessary to process your application.

Application Submitted

Thank you. Your patient application has been received. Our team will review your documentation and respond within 48 hours at the email address you provided.

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