Submit Vaccine Injury | Cornwall Vax Victims

Submit a COVID-19 Vaccine Injury

Below is a vaccine injury form which can be filled out by either the person affected, a family member, carer or friend.

All entry information is about the vaccine injured person apart from the question 'Who is filling out this form?'

All information submitted will remain confidential and no identifiable data i.e name, email address will be shared with anyone unless you have given your express permission to share.

COVID-19 Vaccine Injury

First Name

Last Name

Date of Adverse Reaction

Age

Location

COVID-19 Vaccine Injury

Thank you

We will get back to you soon.

Your data will not be shared with any third parties without your permission or unless you have asked us to do so.

Government YellowCard Scheme Results

In the YellowCard list (image above) we can see, but a few, of the massive range of adverse reactions which people in the UK have been suffering from.

Could you, a relative or a friend have suffered from an adverse reaction?

If you suspect this, please share it with us. We are here to listen.

Help us to understand how the Covid-19 vaccine is negatively affecting those around us, so that we are able to help warn people locally of the dangers.

The listed adverse reactions are not revealed on the leaflet which the doctor or nurse gives to the patient before going for Covid-19 vaccine.

No person has ever been able to give fully informed consent, this is due to the Covid-19 injections being experimental and still in the Phase 3 of testing.

Your Data
Over time we will be combining similar data together i.e adverse reaction type, this will be to analyse the data collected and to see what outcomes there has been from the COVID-19 vaccines.

We may create graphs to show the most frequent injury type but we would not use any of the individuals personal and private data such as names and contact details, unless an individual has requested us to do so, for example, to share a testimony.

Please refer to the Data Protection page to read more on how we will store and use your data.