Please answer all questions fully to the best of your ability. Some questions may not apply to your specific case. In that situation, simply put ‘N/A’ as your entry. If you do not know the answer to a particular question, you should state ‘Unknown’ as your entry.
Please list the names of all known doctors and medical facilities that provided medical treatment for your injuries/conditions mentioned above, along with the approximate dates of treatment. Ex: Dr. John Doe, Boston University Hospital, Chemotherapy (2015-2017)
Please upload the following documents:
a. Pictures of any of the above-referenced hair products still in your possession (container/bottle, bar code, etc.)
b. Pictures of any form of proof-of purchase such as receipts for the above referenced hair products or salon services
If you are unable to upload the documents, please email them to email@example.com. If you are unable to provide digital copies, please mail physical copies to our Alabama Office at 1 Saint Louis Street, Suite 1002, Mobile, AL 36602.
Max. file size: 20 MB.
Drop files here or