Elevate Salon Appointment Request

Personal Information

Where are you receiving your treatment? *

About You

First name *

Last name *

Date of birth * (mm/dd/yyyy)

Patient MRN *

Which clinic are you being treated in? *

Where is the site of concern? *

Contact Information

Contact Methods

Your Patient's Email Address

Your Patient's Phone number * (###-###-####)

Alternate phone (###-###-####)

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.

Yes No

May we leave a message if you're unable to answer? * Yes No

Residential Address

Street address *

City *

State/Province *

Zip code *

Country *

Appointment Details

Available Services

Have you already placed an order for a headcovering, or do you already have your headcovering? * Yes No, I need to order a 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. Pretreatment Haircut Wig style, trim and shape Men's wig style, trim and shape Head shave - Inpatient Head shave - Outpatient Hat with hair trim Hair donation haircut

Scheduling

Which stylist would you prefer to see? LaFondra Martin Jeffrey Lindner No Preference

Please select day(s) you are available for an appointment Monday Tuesday Wednesday Thursday Friday

How did you hear about the Resource Center's services? *

Please describe *