OLD - The Smith Law Firm: Client Intake Form

THE SMITH LAW FIRM, PLLC

Client Intake Information
This information helps us get to know more about you, your injury, and how The Smith Law Firm may be able to help you.

We suggest setting aside around 25-30 minutes to complete this form.

Save if you are interrupted:

Click the "Save" button at the bottom of the current page and a link will be emailed to you - note that you do not have to create an account to save - just click on "Skip Create an Account".

Click the link in your email to resume, and you will pick up right where you left off.

To make this process easier for you, take a little time to gather the following info before you begin:
- basic contact info for the hospital or doctor who diagnosed you & for your primary care physician leading up to your diagnosis
- a copy of your cosmetology license, if available
- any copies of relevant medical records you currently have
Ready? Let's begin.
Person Completing Information*
Please select "Injured Party" if you are filling this out for yourself. Those filling this out on behalf of someone else should select "Personal Representative".
IMPORTANT: Be sure to click "Save" as you finish each page so you can pick up where you left off.

After you click "Save on this first page, if you are asked to sign up to Jotform (the background online form tool we use to gather this information) instead click on the small link in that box that says "Skip Create an Account".

The red arrow in the image below shows you where to click.

Now, click "Save" - then click "Skip Create An Account" as in the above image.

You will then enter your email address and click "Send" and an email will be sent with your unique, saved link so you can pick up where you left off.

Once saved, click "Next".

Injured Party Information

Fill this part out for the person who was a hairdresser and was diagnosed with cancer.
Legal Name*

PrefixFirst NameMiddle NameLast NameSuffix
Preferred Name (if different)

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Best Time to Call

If you have a preference, enter it here - if not, leave blank. Minutes

AM/PM Option
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
SSN
Date of Death (if applicable)

MonthDayYear
Date
Gender*
Gender at Birth
Race*
Marital Status*
Spouse's Name*

Secondary Contact Persons

A Secondary Contact Person is someone you trust who may serve as another point of contact in the event the Primary Contact Person is temporarily unavailable. If none, leave blank.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
To save your progress, click "Save", then click "Next".

Personal Representative Information

A Personal Representative is a person who acts on behalf of, and in the best interests of, someone who may be temporarily or permanently incapacitated. If this is you, enter your information here.
Legal Name*

PrefixFirst NameMiddle NameLast NameSuffix
Preferred Name (if different)

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Best Time to Call*

Hour Minutes

AM/PM Option
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
SSN
Gender*
Gender Assigned at Birth
Race*
Do you have power of attorney to act on behalf of the injured party?*

YesNo
Want to get a new link saving your progress to this point?
Click "Save", then "Send".

Then click "Next" to go to the next page.

Secondary Contact Persons

A Secondary Contact Person is someone you trust who may serve as another point of contact in the event the Primary Contact Person is temporarily unavailable. If none, leave blank.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship

Injury Information

Please provide all of the information you can recall.
Describe frequency of usage of hair color products and how products were used (times per day, week, etc.)*

Describe your exposure to hair color products:*

	Brands or Manufacturers	Product Name	Date or Date Ranges of Exposure	City & States where you were exposed	Name of Salon where you were exposed

Do you have proof/evidence of your usage of these products (i.e., receipts, photos of products)? If yes, please retain them as we will ask for those records at a later date.*

YesNo
Injury – mark all that apply.*

Bladder CancerLeukemia or LymphomaBreast CancerOther
Date of diagnosis of above injury*

MonthDayYear
Date
Hospital/doctor that diagnosed above injury*
Hospital/doctor Phone Number
Please enter a valid phone number.
Hospital/doctor Address

Street Address

Street Address Line 2

CityState or Region

Postal / Zip CodeCountry
Don't risk losing all of the info you just entered!

Click "Save", then "Send" to have a new save point sent to your email.

Then click "Next" to go to the next page.

Current treatment for injuries – Hospitals, doctors, etc.

Please enter as much information as you can recall.
Name of Primary Care Physician leading up to your diagnosis *
Address of Primary Care Physician leading up to diagnosis

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Primary Care Physician leading up to diagnosis
Please enter a valid phone number.

Treating physicians, facilities and hospitals*

	Doctor or Facility	City and State	Type of Treatment (ex.: Chemo, Surgery)	Years Treated by Provider (ex: 2021-2022)

Treatment Required*

ChemotherapyRadiationSurgeryOther
Describe your current condition (i.e., in treatment, cancer-free)*
Future treatment needed, if any?*
That is a lot of information - want to ensure it is saved and that you can pick up right here if you are interrupted? Click "Save" and then "Send" to get an email marking your current progress.

Ready to keep going? Click "Next".

Personal History
Are you a current or former smoker?*

CurrentFormerNever Smoked
How often and how much do you/did you smoke?*
Please specify the number of years, months you smoked.*
Date Last Smoked*

MonthDayYear
Date
Have you consumed drinking water with high levels of arsenic?*

YesNo
Has your primary source of drinking water ever been from a private ground well?*

YesNo
Have you ever taken the Chinese herbal supplement Aristolochia fangchi?*

YesNo

You're almost done!

On the next page you can choose to upload any of the documents you may have readily available. Don't have them? No worries, we can reach back out to you later to get what we need.
If you have some of these, feel free to upload them:

If you are the Injured Party:
- Injured party’s birth certificate
- Injured party’s driver’s license or other state-issued photo identification
If you are a Personal Representative:
- Personal representative’s driver’s license or other state-issued photo identification
- Injured party’s death certificate (if Injured party is deceased)
- Power of attorney (if you have power of attorney)
- Injured party’s Marriage License (if you are the spouse)
IMPORTANT: Don’t have all of these yet?

We will be sure reach out to you for anything we need later.

Documents to upload - Personal Representative

Don't have some of these readily available, or having problems uploading? No problem, just upload what you can and then click either "Save" or "Next" - you are almost done!
Personal representative’s driver’s license or other state issued identification

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Injured party’s death certificate

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Power of attorney

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Next of kin affidavit

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Injured party’s Marriage License if personal representative is spouse

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Injured party’s Cosmetologist license

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Any contracts with cosmetics companies

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Any copies of medical records

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Any additional records you may want to provide

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Are there some documents that you need to send via USPS Mail or FedEx?

Documents to upload - Injured Party

Don't have some of these readily available, or having problems uploading? No problem, just upload what you can and then click either "Save" or "Next" - you are almost done!
Injured party’s birth certificate

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Injured party’s driver’s license or other state issued photo identification

Cancelof
Injured party’s Cosmetologist license

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Any contracts with cosmetics companies

Cancelof
Any copies of medical records

Cancelof
Any other relevant records you may want to provide

Cancelof
Are there some documents that you need to send via USPS Mail or FedEx?

Thank you for taking the time to provide this important information. Next up, click the submit button to send it to The Smith Law Firm and we will begin processing it.
Should be Empty:

THE SMITH LAW FIRM, PLLC

Injured Party Information

Secondary Contact Persons

Personal Representative Information

Secondary Contact Persons

Injury Information

Current treatment for injuries – Hospitals, doctors, etc.

Work

Personal History

Medical History

You're almost done!

Documents to upload - Personal Representative

Documents to upload - Injured Party