Talcum Powder Pre-Qualification Form

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Have you or a loved one regularly used talcum powder products such as Johnson’s Baby Powder or Shower to Shower?

Yes

No

Did you use talcum powder products regularly for 5 or more years?

Yes

No

Which product(s) did you use? (select all that apply)

Johnson’s Baby Powder

Shower to Shower

Other talcum-based powder

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

Were you diagnosed within the last 10 years?

Yes

No

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, 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 case review.

Talcum Powder Was Part of Your Daily Routine. The Damage Wasn’t.