VACCINE INJURY FORM SUBMISSION

Please click here to learn more about our Vaccine Injury Initiative!

"Informed Consent" (As defined by the Canadian Medical Protective Association):

The patient must have been given an adequate explanation about the nature of the proposed investigation or treatment and its anticipated outcome as well as the significant risks involved and alternatives available.
The obligation to obtain informed consent must always rest with the physician who is to carry out the treatment or investigative procedure.

Today's Date

First Name

Last Name

Telephone Number

How did you hear about the We Unify Canada vaccine injury initiative?

Why did you choose to take a Covid-19 vaccine?

Do you feel you were adequately educated, as to the risks, benefits and alternatives, as to provide informed consent, prior to receiving the vacccine? (See top of form for definition of informed consent)

Yes

What injury/injuries have you suffered?

Why do you believe that the injury/injuries are a direct result of the vaccination?

Has a medical professional confirmed that the injury/injuries is a direct result of the vaccination?

Yes

Your story

Age

How has your life changed since receiving the vaccine? Are there any activies or otherwise that you can no longer engage in?

Do we have your consent to share your story? This could include, but is not limited to, class action suits, news articles and/or documentaries.

Yes

Please attach any documentation relevant to your vaccine injury

Upload File

We are gathering video testimony of those suffering vaccine injuries. If you would like to share your account on video, please upload it here:

Upload File

Thank you for your request. We Unify Canada is a volunteer organization. We will address requests in the order in which they are received. We appreciate your patience.