Application

Eligibility Requirements

  • Must be 18 years old or younger

  • Must be treated for medical hair loss in Illinois

  • Completed application

  • Referral letter from your treating physician

Application

To apply for financial assistance, you can:


(1) Complete electronic form.

(2) Print and send in a completed paper copy. Please be sure to read instructions on how to complete the downloaded application form. 

Additional Forms