Tell Us About Yourself Name* First Last Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code GenderFemaleMaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Phone*Are you experiencing medical hair loss?*Are you experiencing medical hair loss? Yes No Please select any of the following medical conditions for which you are diagnosed:*Please select any of the following medical conditions for which you are diagnosed: Alopecia hair loss Cancer-related hair loss Chemotherapy-related hair loss Kidney disease-related hair loss Radiation-related hair loss Thyroid-related hair loss Certain scalp infections Certain medications for medical conditions, such as high blood pressure and heart problems Other, please specify: Other medical condition(s):*Other medical condition(s): Would you like Sereen to support you with filing an insurance claim on your behalf?*Would you like Sereen to support you with filing an insurance claim on your behalf? Yes No PRIMARY MEDICAL INSURANCE INFORMATIONWith everything else going on, learning about the ins and outs of wigs and your insurance should be the last thing you have to think about. We provide free expertise in insurance billing and navigating the healthcare industry. We’re the first hair studio that will submit a health insurance claim on behalf of our clients and we’ll assist with your reimbursement. Note: Sereen is an out-of-network provider I do not have medical insurance, Medicare, Medicaid or any commercial or government-funded health benefit plan. Insurance company, Medicare or Medicaid plan*First ChoiceSecond ChoiceThird ChoiceMember number / ID number* Group number Who is the policyholder?*First ChoiceSecond ChoiceThird ChoicePolicy Holder Information (If not self) First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber Number Share a clear image of your insurance card (recommended)Provide images of the front and back of your insurance card so we can submit a claim on your behalf. Drop files here or Select files Max. file size: 16 MB. Please upload your medical script with your diagnosis codeDon’t have this on hand? Bring a copy to your VIP Beauty consultation or have your medical provider’s office fax it to us at 631-532-4333 Drop files here or Select files Max. file size: 16 MB. Are you in need of additional financial assistance?Beyond our assistance with insurance coverage, you may be eligible for the Sereen Discount, local grants, and other financial support. Yes No Share a clear image of your State IDProvide images of the front and back of your state ID so we can verify your identity. Drop files here or Select files Max. file size: 16 MB. PhoneThis field is for validation purposes and should be left unchanged.