vax injuries | Mike Yoder, Esq.

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2300 Wilson Blvd. Ste 700

Arlington, VA 22201

e: info@yoderesq.com

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1. CONTACT INFO

First Name

Email

Last Name

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

2. INJURED PERSON

Relationship to the injured person (or say "myself"):

Current status of injured person

Deceased

Hospitalized

Care Facility

At Home

Other

If "other" please explain:

If you are not the injured person, please provide the following information:

Injured Person's First Name

Email

Injured Person's Last Name

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Injured Person's Birth Date:

Vaccine Received:

Pfizer-BioNTech

Moderna

Johnson & Johnson

Other

Vaccine Administrator: (Name of practice, pharmacy, nursing home, hospital, etc.)

Date of 1st Vaccination

Injured After Dose #1?

Yes

No

Not sure

Date of 2nd Vaccination

Injured After Dose #2?

Yes

No

Not sure

Did injured person receive more than 2 doses?

Yes

No

Is Injured Person Deceased (if yes, please provide date)

Date of First Treatment:

Date of First Symptom:

Describe your initial symptoms:

List of Treatment Provider(s):

Diagnosis:

Thank you. We will contact you shortly.

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1. CONTACT INFO