Post Vaccine Reactions Form1Tell Us2Who3What4EffectsYour name, phone number and email will not be displayed on this website, the rest of the information will.The Adelaide Freedom Rally team we will use your information to verify your story if we feel it requires. All of your entered information will be compiled into a spreadsheet to be used as we see necessary to alert South Australian officials of the growing body of concerning post-vaccination experiences.What are you reporting?* Post Vaccine Reaction Post Vaccine TransmissionWe collect this data for verification of events only. It will not be published.First Name*Last Name*Email* PhoneWould you like to subscribe to the email list? Yes, Subscribe meThese fields will be displayed, please take care to protect your identity if you do not want it published. The date you enter this form will automatically be published.Is this your personal experience?* Yes this is my experience No this is someone else's experienceFirst NameAgeGenderVaccine brand received?* Pfizer AstraZeneca Not SureFirst Dose Date* DD slash MM slash YYYY Second Dose Date* Had Planned Not HavingSecond Dose Date DD slash MM slash YYYY Did your experience require* Ambulance GP Visit HospitalWhich dose did you experience your reaction* First Second BothHave you shared your story anywhere else?If yes, please provide links, if no please leave blank.Describe your symptoms/experienceImage Uploads Drop files here or Select filesAccepted file types: png, jpg, jpeg, Max. file size: 128 MB, Max. files: 4.Please limit to 2mb per imageNameThis field is for validation purposes and should be left unchanged.
