Injury Form - Oklahomans for Health & Parental Rights

Injury Form

Fields marked with an <span class="ninja-forms-req-symbol">*</span> are required

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We understand that many of you are not being helped, believed or are fearful to publically share your experience. If you are an Oklahoman, who has experienced an injury or death from a vaccine, regardless if your case has been reported to VAERS, we want to hear your story.

First Name *

Last Name *

Email *

Phone *

Address *

VAERS Report Number

Vaccine(s) *

Please detail the vaccine injury here *

Please check here if you give OKHPR permission to share your story.

If you have given OKHPR permission to share your story, please check here if you wish to remain anonymous.

Please check here if you would be willing to speak publicly about your experience.