Picture Before Vaccine Injury *Please upload only .jpg or .png format images.
No image selected
Picture After Vaccine InjuryImages are optional but they have much more of an impact so please try and upload them. Please upload only .jpg or .png format images.
Most Recent PictureImages are optional but they have much more of an impact so please try and upload them. Please upload only .jpg or .png format images.
Name of Vaccine Injured *Enter first name only
Age at Vaccine Injury *Approximate if exact age is unknown
Date of Vaccine Injury
Month of Vaccine Injury *
Year of Vaccine Injury *
Vaccines Causing Vaccine Injury *Select all that were given at time of vaccine injury
Other vaccine
Vaccine InjuryBriefly describe vaccine reaction (e.g. rash, seizures, SIDS, etc.)
Abilities Lost At Time of Vaccine InjuryBriefly describe abilities lost (e.g. walking, talking, joint mobility, etc.)
Change In Abilities Since Vaccine Injury
Name *Required so we know that you are a real person. Your name will not be shared with anyone and will not be posted publicly.
Anonymous
Email *Required so we know that you are a real person. Your email will not be shared with anyone and will not be posted publicly.
Relationship To Vaccine Injured
City
State *
Country *
Mentions if Others
Enter the destination URL
Or link to existing content
