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First Name
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Last Name
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Email Address
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Mobile Number
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Date of Vaccine
*
Month
/
Day
/
Year
Type of Vaccine In Question
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Please Select
Chickenpox/Varicella
Flu
Hepatitis A
Hepatitis B
HIB
HPV
Meningitis
MMR
PCV
Pneumococcal
Pneumonia
Polio
Prevnar
Rotavirus
Tetanus/TDaP/DTaP
Date of First Symptom
*
If you don't have an exact date, a general timeframe is okay.
Month
/
Day
/
Year
Type of Vaccine Injury
*
Please Select
ADEM/Encephalopathy
Anaphylaxis
Autoimmune Disorder
Bell's Palsy
Brachial Neuritis/Ulnar Neuropathy/Parsonage Turner Syndrome
CIDP
Complex Regional Pain Syndrome
Encephalitis
Guillain-Barre Syndrome
Immune Thrombocytopenia
Intussusception
Neuropathy-Related
Shoulder Injury
Syncope
Thrombocytopenic Purpura
Transverse Myelitis/Neuromyelitis Optica
Date of First Treatment
Put your scheduled date if it hasn't happened yet. If you haven't treated, you can skip this question.
Month
/
Day
/
Year
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