Stylist Insurance Order Form
Report your client’s cranial prosthesis installation details and the exact amount paid for the insurance claim.
Stylist Information
Stylist Full Name
*
First Name
Last Name
Salon or Business Name
Stylist Email Address
*
example@example.com
Stylist Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Information
Client Full Name
*
First Name
Last Name
Must match the name on the client's Medical and Insurance Intake Form
Hair System Details
Hair Color / Shade Name
*
The shade name or number of the hair used
Length
*
Please Select
18 inch
22 inch
Other/Custom
Texture
*
Please Select
Straight
Wavy
Curly
Total Amount the Client Paid
*
The complete price your client paid you for the hair system and installation together. This exact number is what her insurance claim will be filed on.
The total reported above will be submitted to the client's insurance carrier on an insurance claim. By signing below, I attest that this amount is exactly what my client actually paid me for this hair system and installation. I understand that reporting an inflated or inaccurate amount on an insurance claim may constitute insurance fraud.
I confirm the total above is exactly what my client paid me
*
I confirm the total above is exactly what my client paid me
What is your clients Full Name
*
What is your clients phone number including area code
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Order Number
*
Your Kelly Maxwell Hair Extensions order number for the hair used in this installation
Submit
Submit
Should be Empty: