Chinese Drywall Intake Form
Date
Name
Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Email
What makes you believe that the dry wall board in your house might be the Chinese wall board ? (Fumes/Evidence of Corrosion)
Is your home new or has it been remodeled after Hurricane Katrina
Approximated date of construction/remodel when Chinese Drywall ws used:
Name of Builder/Contractor
Builder's/Contractor's Phone and/or Address
Number of People (including children) living at this address since rebuilt/purchased
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Full Name
Date of Birth
Full Name
Date of Birth
Full Name
Date of Birth
Full Name
Date of Birth
Full Name
Date of Birth
Full Name
Date of Birth
Full Name
Date of Birth
Do you have photographs of the damage?
Yes
No
(If not please take some photos and send them to us)
Do you have Breathing or allergy problems?
Yes
No
Have you been to a doctor in relation to these complications?
Yes
No
If so Please provide Name, Address and Phone Number of treating Physician
Please enter the two words into the text box below then click submit