Under 18’s Adverse Reactions Report

Please use the form below to report any adverse reactions / side effects you have witnessed in a child (any person under 18 at time of vaccination) you know since having their recent Covid-19 vaccine.

Please note that this form is for residents of the U.K. only.

Your Title *

Your First Name *

Your Surname *

Your Email *

Your relationship to child *

Child's date of birth *

Was the child previously confirmed as having Covid? *

Yes
Yes (confirmed via antibody test)
No

If the child had an antibody test what was the result?

Date of their first vaccination

Date of their second vaccination

Date of first symptoms

Days missed from school

The side effects the child suffered *

Declaration *

I understand that any information I provide to Covid19 Assembly will be held in accordance with its data protection policy and may be shared in confidence with PJH Law and Jackson Osborne Solicitors who may contact me directly in respect of the information I have provided.to legal challenges relating to the use of Covid-19 vaccines/gene therapies. I confirm I have permission to share the information I am providing. Following the submission of this form I agree to receiving emails from Covid19 Assembly relating to any services or campaigns supported via its website. I also understand that I can opt out of this agreement at any time.