Report A Vaccine Injury

Potential safety issues may not be disclosed or fully disclosed to individuals receiving vaccines. Vaccines can cause injury weeks or months after injection. If you have received a vaccine and suffered an adverse event, please fill out the form below and we may be able to connect you with appropriate medical and legal assistance. Please also file a VAERS report!

Fields marked with an * are required

Name *

Email *

Phone *

ZIP Code *

Approximate Date Vaccine Received *

Vaccine(s) Received *

How long after vaccine did injury begin *

Description of the injury *

Date of birth *

Sex *

Date and time of vaccination *

Date and time the adverse event (health problem) started *

Age at vaccination *

Pregnancy due date (if applicable)

Any medications (or supplements) being taken *

Allergies *

MonTueWedThuFriSatSun

242526272812345678910111213141516171819202122232425262728293031123456

MonTueWedThuFriSatSun

242526272812345678910111213141516171819202122232425262728293031123456

MonTueWedThuFriSatSun

242526272812345678910111213141516171819202122232425262728293031123456

MonTueWedThuFriSatSun

242526272812345678910111213141516171819202122232425262728293031123456

MonTueWedThuFriSatSun

242526272812345678910111213141516171819202122232425262728293031123456