New Client Chemical Hair Relaxer Questionnaire

Instructions

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

First Last

Phone

Current Address

Street Address Address Line 2 City State ZIP / Postal Code

Within What County Is Your Current Residence Located?

Emergency Contact (Name & Phone Number)

Your Date of Birth

Your Social Security Number

Have you ever declared bankruptcy? If so, has the bankruptcy been resolved?

DO NOT file bankruptcy during pending litigation without first consulting your Attorney as it may impact your ability to recover settlement proceeds.

What is your marital status/history?

If you are married, please list your spouse’s full name.

Hair Relaxer Product Information

Approximately what years did you START and STOP using Hair Relaxer products?

Please provide the approximate date and location (city, state) that you last purchased a Hair Relaxer product.

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.

Dark & Lovely, Ultra Sheen, Etc. by L’Oréal

ORS Olive Oil Hair Relaxer by Namaste

Just For Me by TCB Naturals (Godrej Consumer Products)

Motions by Strength of Nature Global

Optimum Salon by SoftSheen Carson

Other

If you selected "Other" in the list above, please provide the product name, manufacturer, and location where item was purchased.

Please list the name and address of each Hair and/or Beauty Salon that has treated or styled your hair in the last 10 years. If you use an independent or freelance hairstylist that is not associated with a Salon, please provide their name and contact information.

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.

Uterine Cancer

Endometrial Cancer

Ovarian Cancer

Other

If you selected "Other" in the list above, please describe the injury/condition in detail.

Your Medical Providers

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)

Do you have children? If so, please list their ages.

Have you ever experienced issues with infertility?

Miscellaneous

Please provide any other facts or information you believe may be relevant to your case:

Upload Relevant Documents

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 admin@foster-law.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.

Drop files here or

Max. file size: 20 MB.

This field is for validation purposes and should be left unchanged.