Get Updated If/When COVID-19 is Covered by the VICP
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Title
Please select...
Ms.
Mrs.
Mr.
Dr.
Prof.
Chief
Hon.
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)
Date of Booster 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
Fainting
Myocarditis
Polymyalgia Rheumatica (PMR)
Polyneuropathy
Pemphigus
Rash
Seizures
Transverse Myelitis
Tinnitis / Ringing in the Ears or Hearing Loss
Vasculitis
No Diagnosis
Other
If Diagnosis is Other, please list:
Did you get any OTHER vaccines in the 45 days BEFORE your symptoms started that may qualify you for the VICP?
YES
NO
If YES, which one(s):
Flu/Influenza
Diptheria
Tetanus
Pertussis
DTap
TdaP
Measles
Mumps
Rubella
MMR
Hepatitis B
Varicella (Chickenpox)
Rotavirus
Pneumonia
Hepatitis A
Meningococcal (Meningitis)
HPV
None of the Above
Describe Your Vaccine Injury
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