Post Vaccine Reactions Form - ADELAIDE FREEDOM RALLY

Your 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 Transmission

These 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 experience
First Name
Age
Gender
Vaccine brand received?*
- Pfizer
- AstraZeneca
- Not Sure
First Dose Date*
DD slash MM slash YYYY
Second Dose Date*
- Had
- Planned
- Not Having
Second Dose Date
DD slash MM slash YYYY

Did your experience require*
- Ambulance
- GP Visit
- Hospital
Which dose did you experience your reaction*
- First
- Second
- Both
Have you shared your story anywhere else?
If yes, please provide links, if no please leave blank.
Describe your symptoms/experience
Image Uploads
Drop files here or

Accepted file types: png, jpg, jpeg, Max. file size: 64 MB, Max. files: 4.
Please limit to 2mb per image
Name
This field is for validation purposes and should be left unchanged.

Adelaide Freedom Rally