Hair Peace Foundation Patient Application

Important Notice: While email consultations are free, please note that virtual and in-person consultations are billed at standard rates. Submitting this form is for qualifying for pro-bono work—it does not guarantee free services. We will review your application and inform you of your eligibility. 

Personal Information
Medical History
Financial Information
Annual Income: Please attach supporting documents (e.g., pay stubs, tax returns) for verification purposes.
Additional Information
Please provide any details about your condition, circumstances, or motivations for seeking care through the Hair Peace Foundation's pro-bono program. Uploading recent photos of your condition is required.
Commitment
Are you committed to attending all scheduled appointments and following treatment recommendations provided by the Hair Peace Foundation?

Thank you for your interest in receiving care from the Hair Peace Foundation. Your health and well-being are our top priorities, and we look forward to assisting you on your journey towards healing and recovery.

SCALP AND HAIR WELLNESS FOR ALL
Quick Links
Contact Details

(310) 318-1500

1-800-499-DRUCLINIC

patient.care@dru.com

2121 N Sepulveda Blvd #200

Manhattan Beach, CA 90266

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