Elevate Salon Appointment Request

We know how important it is for you to feel like yourself throughout your cancer treatment.

Our professional team looks forward to helping you with your wig and headcovering selections. Please complete the form below and we will give you a call to schedule your appointment.

Fields marked with an asterisk * are required.

Personal Information

About You

Contact Information

Contact Methods

May we say we're calling from Roswell Park? *

Due to HIPAA regulations, Roswell Park will not be able to identify itself to someone other than you or in a voice message, unless you indicate otherwise.

May we leave a message if you're unable to answer? *

Residential Address

Appointment Details

Available Services

Have you already placed an order for a headcovering, or do you already have your headcovering? *

Please prepare for your headcovering consultation by looking through our catalog. Available products begin on page 16.

What service is needed? * Check all that apply.


Which stylist would you prefer to see?
Please select day(s) you are available for an appointment