Please complete this form as much as possible so we can best deturmin your qualification for the Mass Tort case.

Contact information

Prefix

First name *

Middle name

Last name *

Date of birth

Company

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

DOB

SSN

DOD if applicable:

Did you or a loved one use a hair straightening or relaxing product?

Usage Information

note there is room for 3 different products, only fill out based on your usage.

Product type (1)? Brand/Manufacturer

Date(s) of use (1)? MM/YY - MM/YY

Frequency (1)? Times per year

Where was product purchased (1)? City, State

If used in salon, provide salon name and location (1).

Product type (2)? Brand/Manufacturer

Date(s) of use (2)? MM/YY - MM/YY

Frequency (2)? Times per year

Where was product purchased (2)? City, State

If used in salon provide salon name and location (2).

Product type (3)? Brand/Manufacturer

Date(s) of use (3)? MM/YY - MM/YY

Frequency (3)? Times per year

Where was product purchased (3)? City, State

If used in salon provide salon name and location (3).

Injury Info

Have they been diagnosed with cancer OR uterine fibroids? If yes, which?

Date of Cancer Diagnosis?

Diagnosing Physician or Hospital?

Treating doctor(s) and hospital(s)?

Please list any additional complications and/or reactions as a result of the product use.

What is the current status of injury/illness?

Have you had any of the following procedures? Hysterectomy, myomectomy, endometrial ablation, Uterine Artery Embolization (UAE/UFE), or curettage (D&C), if yes which and when.

SUPPORTIVE INFORMATION

What is your or your loved one's ethnicity? American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, or Other