Please complete the following questionnaire regarding your Hair Relaxer case.

Chemical Hair Relaxer Questionnaire


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.

Personal Information

Your Name
Current Address
Your Date of Birth
DO NOT file bankruptcy during pending litigation without first consulting your Attorney as it may impact your ability to recover settlement proceeds.
If you are married, please list your spouse’s full name.

Hair Relaxer Product Information

Please select all hair relaxer products that you have used in the past 10 years. Note: these are Brand-Name products. Your hair relaxer product could be the same product on the list but marketed under a different name.

Medical Information

Please list all injuries you believe may be related to your exposure to Chemical Hair Relaxers:
Check all that apply and list approximate date of diagnosis in the “Other” field below.
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 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.
Drop files here or
Max. file size: 20 MB.
    This field is for validation purposes and should be left unchanged.