Hair Relaxer Pre Qualification Form

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Did you use chemical hair relaxers or straighteners regularly for 2 or more years?

Yes

No

Have you been diagnosed with any of the following? (select all that apply)

When were you diagnosed?

2013 or Later

Before 2013

Are you currently represented by an attorney for this matter, or have you previously worked with an attorney regarding this claim?

Yes

No

I confirm that all information provided is truthful and accurate. I understand that my claim will require verification through medical records, proof of product usage, identification, and any other supporting documentation. Providing false information will result in immediate disqualification.

I consent to being contacted by Poca Lead Logic by phone, email, or text regarding my potential case.

Beauty Shouldn’t Cost You Your Health.