HaLo Funds Vaucher Application

The Pink Pamper HaLo Fund was established to help women who have experienced the trauma of hair loss due to chemotherapy by providing financial assistance in the form of a $350 voucher towards the purchase of a beautiful, natural- looking wig at Hair Enhancements of Pittsburgh. Hair Enhancements of Pittsburgh, our exclusive partner in this effort, carries an assortment of helpful accessories including hats, hair products and wig supplies, in addition to the best synthetic and human hair wigs currently available.

Name(Required)

Date of Birth(Required)

How Did You Hear About Us(Required)

Phone(Required)

Email(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Do You Rent

Rent

Own

Other

Please check beside each item below that refers to your own household

Household Information

Spouse/Significant other

Children under 12

Children 13 and up

Total number of household members (including the patient):

Yearly Income Range

$1 - $10,000

$10,000 - $25,000

$25,000 - $50,000

$50,000 - $75,000

$75,000 or above

Please place a check mark beside your corresponding income range

Name of Your Oncologist(Required)

Disclaimer:

I understand that the information I provide will be kept confidential. I understand that if any information I have given is determined to be false, it may result in not being provided with a voucher.

I agree to fill out a survey prior to me receiving my final fitting of my wig.(Required)

I certify that the above information is true and accurateto the best of my knowledge.(Required)

Signature of Patient(Required)

Approval of Voucher Signature(Required)

Voucher Number(Required)

Date(Required)

Pink Pamper HaLo Fund
Voucher Application

Please check beside each item below that refers to your own household

Disclaimer:

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Pink Pamper HaLo FundVoucher Application

Please check beside each item below that refers to your own household

Disclaimer:

Pink Pamper HaLo Fund
Voucher Application