The Smith Law Firm: Hair Color 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. Most hairdressers complete this form in about 10 minutes.

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".
You can click SAVE on any page to receive an email that helps you pick right up where you left off.
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.

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
Why? Medical providers often require your social security number to ensure that they are not sharing another person's HIPAA-protected information, just your medical info. Additionally, courts require it to ensure the unique identity of each plaintiff.
Date of Death (if applicable)

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

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
Why? Medical providers often require your social security number to ensure that they are not sharing another person's HIPAA-protected information, just your medical info.
Gender*
Gender Assigned at Birth
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

Please list at least one person who can help us contact you or carry on your case in case you are deceased or disabled
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

Injured party, please provide all of the information you can recall.

If you are a Personal Representative, please answer the remainder of the information on behalf of the Injured Party.
Injury – mark all that apply.*

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

MonthDayYear
Date
Hospital, city and state that diagnosed above injury*
Doctor that diagnosed above injury*
Oncologist and/or Facility that primarily treated your cancer, plus city and state where located *
Are you a current or former smoker?*

CurrentFormerNever smoked
If you are a current or former smoker, how often and how much do you/did you smoke?
If you are a current or former smoker, please specify the number of years, months you smoked?
Date last smoked?
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, plus city and state *
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*

Rows	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".

Work
Are or were you a licensed cosmetologist?*

YesNo
What state(s) are or were you licensed in?*
License No. (if available)
Year first licensed*
Is the license current/active?*

YesNo
Describe frequency of usage of hair dye products and how products were used (times per day, week, etc.)*

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