Hair Care Kit | Keep Your Crown

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Please fill out this form to apply.

First name*

Last name*

Email address*

Phone number*

Address*

Location you are receiving scalp cooling*

St. Clair Health Cancer Center affiliated with UPMC Hillman

Other

Check if you HAVE already been in contact with Cooler Heads

Check if you HAVE NOT been in contact with Cooler Heads yet

Hair Type*

1 (straight)

2 (wavy)

3 (curly)

4 (coily)

Hair color/additional characteristics of hair type *

Tell us a little about yourself (age, diagnosis, treatment plan, family, occupation, hobbies, etc.) - OPTIONAL

Check if you have small children.

Method of delivery*

Porch drop-off

Meet/pick-up

Either of the above

keepyourcrownpgh@gmail.com

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