Second Act > About Us > Pre-Visit Registration Form

Pre-Visit Registration Form

In anticipation of your visit to Second Act, we invite you to pre-register. This will allow us to be sure we have the correct products on-hand for your visit.

If you are coming to see us about a wig or hairpiece, a description of the color, length, or style (curly, straight) of your hair would be helpful. We also invite you to upload a current photo if you have one.

If you are coming to see us about a prosthesis and/or bras, it will be helpful to know your current size. Of course this is just for reference as we will measure you during your visit to assure a proper fit. Also, please wear a bra and, if possible, a plain, light colored shirt when you come to visit us.

Please check with your insurance company to confirm your coverage prior to your visit. Many private insurance companies follow the guidelines established by Medicare but not all insurance companies do so. Therefore, it is critical that you know what your insurance company covers and what it does not. Also please confirm with them what documentation they will require in order for you to be reimbursed.

To help you better understand what insurance information you need please visit our Resources page and click on Insurance Information

Pre-Visit Registration Form

First Name:*
Last Name:*
Address:*
City:*
State:*
ZIP:*
E-mail address:*
Phone:*
Birth Date:*	(mm/dd/yy)

Date of Surgery:	(mm/dd/yy)

Date Chemotherapy / Radiation began:	(mm/dd/yy) (or is scheduled to)
Date completed:	(mm/dd/yy) (or is scheduled to)

Reason for the visit:	Wig Prosthesis Bra (check all that apply)

Are you currently wearing a post-surgery bra?
When did you purchase your last post-surgery bra?	(mm/dd/yy)
Current bra size, if applicable:
Are you currently wearing a breast form?
When did you last purchase a breast form?	(mm/dd/yy)
Current breast form size, if applicable:

Do you have any allergies?*
If so, please list them:
What are some of your favorite activities?

Primary Insurance Carrier:*
Name of Primary Insurance Carrier:*
Group Number:*
Patient ID Number:*
Name of Secondary Insurance Carrier:	(if applicable)


How did you learn about Second Act?
Additional information you wish to supply:
Upload Photo:

* Required field.

Learn More About:

Pre-Visit Registration Form