Form

1201 Pacific Avenue, Suite 600
Tacoma, WA 98402-4384

First Name*

Middle Name

Last Name*

DOB*

Month/Day/Year

Phone number*

Email*

Street address*

City*

State/Region*

Postal code*

Marital status*

Injured Name If Different?

Your Relationship To Injured Person?

Why Are You Completing The Form Rather Than The Injured Person?

Physical Address, if different:(street, city, state):

Preferred method of contact?*

This is a rich text area, you can add whatever copy you like

Date Of Death

If Injured Person Is Deceased

Month/Day/Year

Cause(s) Of Death

Residency at time of Death (city & state)

Has an Estate been opened?*

Have You Been Diagnosed With Cancer*

Have you been diagnosed with Ovarian cancer*

Have you been diagnosed with Uterine cancer*

Have you been diagnosed with Uterine fibroids*

Have you been diagnosed with Endometriosis*

Date of diagnosis

Month/Day/Year

Age at time of diagnosis

What city & state did you live at the time of diagnosis

Approximately when did your symptoms first occur (month & year)

How often have you used straightening products within a 12 month period?*

(Must be 4+ times in a 12 month period. If not, decline)

When did you first begin using hair straightening products (month & year)?*

(Must be at least one year between first use and cancer diagnosis. If not, decline)

Approximately when was your last use of a relaxer (month & year)*

List hair straightening product(s) you have used*

Leave empty if unkown

Do you know if product contains Formaldehyde or Phthalates chemicals*

Indicate if product was used in a Salon or at home*

When did you first realize hair straighteners may have caused your injury?*

How did you first make that connection (tv ad, web story, word of mouth, etc) ?*

Any other details you feel the attorney needs to know?