COVID-19 Vaccine Injury Pre-Claim Questionnaire
First Name
Last Name
Email
Phone
Name of Vaccination
Please select...
Pfizer BioNtech
Moderna
Johnson & Johnson
Other
Date of 1st Vaccination
Date of 2nd Vaccination (if applicable)
Diagnosis
Please select...
Shoulder Injury
SIRVA
Brachial Neuritis
Parsonage Turner Syndrome
Adhesive Capsulitis
GBS - Guillan Barre Syndrome
Blood Clots / Embolism
Stroke
Blood Disorder
Thrombocytopenia or ITP
Bell's Palsy
ADEM
Anaphylaxis / Allergic Reaction
Aplastic Anemia
CIDP
Celulitis
Complex Regional Pain Syndrome
Death
Encephalopathy / Encephalitis
Polymyalgia Rheumatica (PMR)
Polyneuropathy
Fainting
Pemphigus
Rash
Seizures
Transverse Myelitis
Tinnitis / Ringing in the Ears or Hearing Loss
Vasculitis
No Diagnosis
Other
If Diagnosis is Other, please list:
Describe Your COVID-19 Vaccine Injury
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