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News
Menu
Attorneys
Casey Langston Lott
Thomas Orville Cooley
Dustin Colt Childers
Clinton Martin
Jack Simpson
Duncan Lott
Our History
Practice Areas
Personal Injury
Wrongful Death
Auto Accidents
Trucking Accidents
Motorcycle Accidents
Coronavirus Business Insurance Coverage
Dangerous Products
Combat Arms Earplugs
Roundup
Defective Medical Devices
Talcum Powder
Belviq and Belviq XR
Paraquat
Phillips Respironics
Phillips CPAP
NEC Baby Formula Lawsuits
Hair Relaxers and Straighteners Cancer Lawsuits
Locations
Booneville
Booneville Medical Malpractice
Booneville Mass Tort
Booneville Product Liability
Booneville Car Accidents
Booneville Trucking Accidents
Booneville Motorcycle Accidents
Booneville Wrongful Death
Personal Injury Lawyers Tupelo | Langston & Lott
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Langston & Lott, PLLC
Hair Relaxers and Straighteners Cancer Lawsuits Form
Langston & Lott, PLLC
Hair Relaxers and Straighteners Cancer Lawsuits Form
Hair Relaxers and Straighteners Cancer Lawsuits Form
Hair Relaxers and Straighteners Cancer Lawsuits Form
Name
First
Last
Any alias used from start of Hair Relaxer usage
Date of Birth
Month
Day
Year
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Sex
Female
Male
Marital Status
Single
Married
Divorced
Separated
Widowed
Do you have children?
Yes
No
If yes, how many?
Please provide your occupation(s) and dates of employment
Have you ever filed for bankruptcy?
Yes
No
If yes, list year and state of filing.
Is this claim being brought by a representative for the hair relaxer user?
Yes
No
Representative Details
Reason for representative
Minor
Incapacitated
Deceased
Name of representative
First
Last
Relationship of the representative to the hair relaxer user
Representative's Date of Birth
Month
Day
Year
Representative's SSN (last 4)
Representative's Phone
Representative's Email
Representative's Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Usage Details
Approximate FIRST use of the hair relaxer
Month/Year
Approximate LAST use of the hair relaxer
Month/Year
State(s) of residence during hair relaxer use and approximate dates of residency
Month/Year
Identify ALL hair relaxer products user to the best of your recollection=
Check all that apply
Dark & Lovely
ORS Olive Oil
TCB Naturals
Just for Me
Motions
Optimum Salon
African Pride Dream Kids
Other
Other
Duration of usage
Approximate month/year to month/year, or year started/stopped if month is not recalled.
Frequency of Usage
Daily
Weekly
Occasional
Periods of Non-Use (at least 3 months without use)
Other
How did you obtain it?
Was the hair-relaxer applied by your hair stylist?
Yes
No
If yes, identify the stylist(s) or salon(s) where the hair relaxer was applied
Name and address(es) of stores/online sellers where you purchased hair relaxer products
Do you have any record(s) showing any of your purchases?
Yes
No
Medical History
Was the user diagnosed with any type of cancer before you began using hair relaxer?
Yes
No
If yes, identify the type(s) of cancer and date(s) of diagnosis
Indicate the type of cancer or injury the user was diagnosed with after using hair relaxer products
Uterine cancer
Ovarian cancer
Endometrial cancer
Other Cancer
Endometriosis
Hysterectomy
Uterine Fibroids
Other Injury
Other Cancer
Other Injury
Initial Diagnosis Date
Month
Day
Year
Stage of cancer at diagnosis
Stage of cancer currently
Do you have a family history (parents, grandparents, or siblings) of the identified cancer?
Yes
No
If yes, please identify relative
Provide the name(s), specialty (general practictioner; oncologist; or other), address(es) and phone number(s) of your treating physician(s) or healthcare professional
Did you suffer lost wages as a result of your injury?
Yes
No
If yes, please explain
Have you ever been exposed to any of the following cancer cusing substances (check all that apply)
Aflatoxins
Aristolochic Acids
Arsenic
Asbestos
Benzene
Benzidine
Beryllium
1,3-Butadiene
Cadmium
Coal Tar and Coal-Tar Pitch
Coke-Oven Emissions
Crystalline Silica (respirable size)
Erionite
Ethylene Oxide
Formaldehyde
Hexavalent Chromium Compounds
Indoor Emissions from the Household Combustion of Coal
Mineral Oils: Untreated and Mildly Treated
Nickel Compounds
Radon
Secondhand Tobacco Smoke (Environmental Tobacco Smoke)
Soot
Strong Inorganic Acid Mists Containing Sulfuric Acid
Thorium
Trichloroethylene
Vinyl Chloride
Wood Dust
Do you have any of the following cancer risk factors (check all that apply)
Smoking and tobacco use in last 25 years
Alcohol
Lack of physical activity
Overweight or obese
Poor diet
Radiation exposure
Virus infections and other infections
Family history of cancer
Chronic inflammation
Hormone therapy
Immunocompromised
Sartan use (Valsartan, Losartan or Ibersartan)
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