Share Your Vaccine Injury Story

Intro goes here.

Name*
This information will only be used to contact you.
First Last
Email*

This information will only be used to contact you.
Test
- Second Choice
- Third Choice
Attribution*
Each story must have an attribution. It can be something like, "Suzy from Southern California"
Optional: Diagnosis of Affected Individual
Optional: Upload Image
Accepted file types: png, jpg.
This image will appear with your story. Only file formats permitted: jpg or png. File limit: 10MB.
Optional: Video

Provide link to YouTube, Vimeo or other video service.
Your Story*
You may find it easier to type your story elsewhere and then simply copy/paste into this field.
Consent*
I agree.
This is a description of what they are consenting to in terms of our use of their content on our website, social media, newsletters, or whatever.