Customer Order Form

By completing and submitting this form your order for cold caps will come to us.  We will need the two required documents to complete it.

Currently we are having website issues so if the order form is not available, email me directly at and I will place the order.

I will need your Name, Address, Phone, Email, Dr. and facility info, DOB, Diagnosis and Regimen, Start date.  We have equipment available. 

Contact Us
Chemo Cold Caps provides a scalp cooling system. Hair loss prevention is not guaranteed and Individual results may vary. Combining this treatment with other established measures is recommended for the best possible outcome. As with any supplementary medicinal treatment, you should consult with your doctor before using this product.
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