Indoor Tanning and Cancer Questionnaire
Please complete this form if you regularly tanned indoors for a period of time and if you have been diagnosed with skin cancer.
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First Name: *
Last Name *
Your Date of Birth *
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What is your current state of residence? *
Phone Number
Email address *
How would you describe your skin tone/complexion? *
What is your hair color? *
Do you have moles? *
How old were you when you started tanning indoors? *
How old were you when you stopped indoor tanning? *
Describe your tanning history.  Include frequency (visits per week/month/etc), total visits, etc. *
What tanning salon(s) did you go to?  Please include the city and state. *
Did you sign any release or waiver? *
If you signed a release or waiver, do you have a copy?
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What type of cancer have you been diagnosed as having? *
Date of diagnosis *
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DD
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Describe any treatment you have had for your cancer.
What is your current prognosis?
Check here to indicate whether an attorney can contact your potential tanning injury. *
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This form was created inside of Nidel & Nace, PLLC.