Initial assessment for complications related to Covid 19 vaccines. Inalienable Rights Alliance. All answers will be kept confidential! We will be following all HIPAA (Health Insurance Portability and Accountability) rules to protect your information and your privacy.
Email *
Name
Address
City
State
Zip Code
Phone #
I had the Covid 19 shot manufacturered by
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Where did you receive your vaccines?
Did you sign a informed consent form before being administered the vaccine?
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I received the first dose on
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/
DD
/
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I received the second dose on (0ther than J and J)
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/
DD
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YYYY
Did you report your injury to the VAERS system or any other system
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If you did report the injury, do you have the name of the person or persons you reported it to?
Tell us the story of the shot and any complications or adverse effects
List other adverse effects:
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You can describe any combinations of shots you took here:
How many doses did I take?
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When you spoke with your doctor or physician what was their response
The purpose of this form is to capture affidavits to present to the federal government in reporting vaccine injuries that are related to all the vaccines. You will be informed whether or not your affidavit is accepted. A more formal document will be sent in its place if it is accepted. Thank you so much for participating and helping us gather more data for the FDA and US government to make the right decision as its obligation to us as citizens. Our constitution was designed to protect our rights and to prevent us from unnecessary harm. El propósito de este formulario es capturar declaraciones juradas para presentar al gobierno federal al informar lesiones por vacunas que están relacionadas con todas las vacunas.Se le informará si su declaración jurada es aceptada o no.Se enviará un documento más formal en su lugar si es aceptado.Muchas gracias por participar y ayudarnos a recopilar más datos para que la FDA y el gobierno de los Estados Unidos tomen la decisión correcta como su obligación para con nosotros como ciudadanos.Nuestra constitución fue diseñada para proteger nuestros derechos y para evitar daños innecesarios. *
Please donate to the Inalienable Rights Alliance. I would like to donate money the following amount of money, to help the cause and the amount below will help with legal, clerical and internet advertising of these affidavits, to help form a potential lawsuit against the manufacturers of any or all of these vaccine manufacturers as well as, if indicated, the FDA, CDC and other legal entities responsible for reporting and oversighting the Covid 19 trial and authorization of these "vaccines" by the US government. More information to follow. Me gustaría donar dinero la siguiente cantidad de dinero, para ayudar a la causa y la cantidad a continuación ayudará con la publicidad legal, administrativa y en Internet de estas declaraciones juradas, para ayudar a formar una posible demanda contra los fabricantes de cualquiera o todos estos fabricantes de vacunas, así como, si se indica, la FDA, los CDC y otras entidades legales responsables de informar y supervisar el ensayo de Covid 19 y la autorización de estas "vacunas" por parte del gobierno de los Estados Unidos.Más información a continuación. *
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