VICP Case Review Form

Phone

First name

Last name

Email

Date of Vaccination

Month

Day

Year

Injury or Symptoms Developed

Have You Received Medical Treatment for This Injury?

Yes

No

Not yet, but plan to

Unsure

Have your symptoms lasted more than 6 months?

Yes

No

Not sure

Additional Details

Upload Medical Records (Optional)

If you have ER summaries, vaccine records, or doctor notes, you may upload them here. Not required

Link