Langston & Lott, PLLC
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

Address

Street Address City State ZIP Code

Phone

Sex

Female

Male

Marital Status

Do you have children?

Yes

If yes, how many?

Please provide your occupation(s) and dates of employment

Have you ever filed for bankruptcy?

Yes

If yes, list year and state of filing.

Is this claim being brought by a representative for the hair relaxer user?

Yes

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

Representative's SSN (last 4)

Representative's Phone

Representative's Email

Representative's Address

Street Address City 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

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

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

Medical History

Was the user diagnosed with any type of cancer before you began using hair relaxer?

Yes

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

Stage of cancer at diagnosis

Stage of cancer currently

Do you have a family history (parents, grandparents, or siblings) of the identified cancer?

Yes

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

If yes, please explain

Have you ever been exposed to any of the following cancer cusing substances (check all that apply)

Do you have any of the following cancer risk factors (check all that apply)

Langston & Lott, PLLC
Hair Relaxers and Straighteners Cancer Lawsuits Form