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Name*

First Last

Email*

Phone Number

Location: City/State/Country*

City State / Province / Region Country

How did you hear about us?*

Friends
Social Media
My Medical Team
Other

Date of Vaccine*

Date of Injury*

Vaccine Manufacturer*

What was your life like before you received the Covid-19 Vaccine?

Symptoms And Solutions

Describe your Symptoms and the timeline of your reaction.*

Describe the Solutions that helped your Symptoms?

Which Solutions weren't helpful?

When you were at your worst, what percentage would you say your reaction was?

Where are you percentage-wise now with your recovery?

What would you like others to know?

What do you need assistance with most? (For internal purposes only, help us understand where to dedicate our resources)

Access to Medical Care Teams
Lab Work
Medical Treatments
Financial Support due to loss of work
Financial Support due to medical expenses
More Information on research
More information on possible symptoms and solutions

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I am either a direct recipient of REACT-CARE funds or the parent/legal guardian of a REACT-CARE fund recipient.

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I certify that the statements made in the above submission are true and correct to the best of my knowledge, information, and belief.*

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I agree to allow React 19 to share my testimonial publicly on its website, social media, or webinar platforms. I further understand that my testimonial will be posted publicly and React 19 cannot prevent third-parties from sharing it once public.*

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I agree to notify React 19 immediately should I discover inaccuracies in my testimonial in order to maintain the integrity of React 19’s advocacy platforms.*