Fields marked with an * are required
The wigs are donated only to women patients residing in India.
Please email the treatment papers of the woman patient undergoing chemotherapy & her recent photograph post chemotherapy hair loss at email@example.com. The wigs are given only after complete hair loss.
The wig request is registered only after the requisite treatment papers & post Chemotherapy hair loss photograph are received.
After scrutiny, a free synthetic hair wig will be couriered at your address which will take about 4-6 weeks.
I understand that by filling up the form for a free wig donated by Madat Trust, I'm giving consent for the use of my photograph by Madat Trust in any form or medium for the purpose of creating awareness about their activities and for their records. l'll email my photograph with and without the wig.
|Thanks & regards
|Dr Anand Parihar