VaxDamage – Vaccine Injury Report

Vaccine Damage Reporting System

Name *

First

Last

Email *

Phone *

City of Residence *

State of Residence (copy) *

Hospital/Location where vaccine injury occurred. *

Was a VAERS report was filed for your vaccine injury? *NoYesI don't know

If YES, do you have the VAERS case #?

Have you sought legal counsel for your vaccine injury? *NoYes

Do you feel your vaccine injury is something that should be pursued legally? *YesNo

May our Truth for Health Foundation team contact you about your vaccine injury? *

• Yes, Truth for Health Foundation may contact me about my vaccine injury.

Submit