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-Must be 18 years old or younger
-Must be treated for medical hair loss in Illinois
-Referral letter from your treating doctor
Important Notice: If selected, funds will be sent directly to business where wig is being purchased.
To apply for financial assistance, you can:
(1) Complete electronic form. **No download necessary. Form is provided below.**
Note: You will not be able to save any work in progress.
(2) Print and send in a completed paper copy.
Note: Please make sure to read all instructions to prevent delays in your application process.
Electronic Application Form
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