JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Looking for stories of vaccine and/or medical injury; please share what led you to believe your child's injuries were related to vaccines
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Parent first & last name
*
Your answer
Are you an active patient?
*
Yes
No
Dates your child / children were patients
*
Your answer
Are you willing to bring your child to the interview?
*
Yes
No
Give a brief paragraph sharing what led you to believe your child's injuries were related to vaccines
*
Your answer
How soon after vaccine did your child experience side-effects?
*
Your answer
Email Address
*
Your answer
Contact Cellphone
*
Dr. Paul and /or his assistant will call to set up the film session.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report