Wig Waiting List

Please attach an authorization letter from your referring medical specialist and the ICD 10 Code relating to your hair loss condition.

Name*
First
ID Number*
Mobile Number*
Landline Number
Email Address*
Physical Address*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
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Authorization letter*
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Disclaimer*
I agree to provide a letter or photo or both to acknowledge that I received a free wig of my choice to the value of R3000.00 which will be posted on social media.*
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Email: afewgreyhairs@gmail.com
Delia: 082 465 7075
11-8th street, linden, Johannesburg