Warp Speed Legal
Member > Log In
Member > Log In
Attorney Portal
Menu
Home
About
Services
Who can we help?
My legal issue
Open menu
Vaccine Injury
Remdesivir Liability
Malpractice Case
Claim Against US Company
Breach of Contract
Employment / Disability Claims
Death By Hospital
Workers Compensation
Experts
Whistleblowers
Attorneys
Contact
Home
About
Services
Who can we help?
My legal issue
Open menu
Vaccine Injury
Remdesivir Liability
Malpractice Case
Claim Against US Company
Breach of Contract
Employment / Disability Claims
Death By Hospital
Workers Compensation
Experts
Whistleblowers
Attorneys
Contact
Vaccine Injury
Step
1
of
20
5%
Did you suffer a vaccine injury?
(Required)
Yes
No
Not sure
What date?
MM slash DD slash YYYY
How many shots did you receive?
Where did you receive them?
Vaccine center
Doctor’s Office
Other
Please give us exact address
Were you coerced, incentivized or mandated to take them?
Yes
No
What is the name of the company, organization or government agency that coerced, incentivized or mandated it?
How soon after the last shot did you experience symptoms?
Immediately
Almost Immediately
One hour
Several hours
The next day
A few days
One week
Two weeks
One month
Two months
Several months
One year
Other
Please Explain
First symptoms I experienced
Fatigue
Exercise Intolerance
Brain Fog
Heart Palpitations
Tingling (numbness)
Muscle Weakness
Dizziness
First symptoms I experienced
Muscle Aches
Sleep Disturbances
Anxiety / Adrenaline Surges
Join Pain (Arthritic)
Shortness of Breath
High Heart Rate
Insomnia
First symptoms I experienced
Nerve Pain
New Persistent Headaches
Muscle Twitching / Tremors
Feeling off balanced
Heaviness in Legs
Memory Loss
Rashes / Hives / Bruising
Were you able to return to work?
Yes
No
Not applicable
Please explain how this has affected your ability to return to work?
Currently I am experiencing…
Fatigue
Exercise Intolerance
Brain Fog
Heart Palpitations
Tingling (numbness)
Muscle Weakness
Dizziness
Currently I am experiencing…
Muscle Aches
Sleep Disturbances
Anxiety / Adrenaline Surges
Join Pain (Arthritic)
Shortness of Breath
High Heart Rate
Insomnia
Currently I am experiencing…
Nerve Pain
New Persistent Headaches
Muscle Twitching / Tremors
Feeling off balanced
Heaviness in Legs
Memory Loss
Rashes / Hives / Bruising
Currently I am experiencing...
Additional Information
Were you diagnosed with any of the following?
Myocarditis / Pericarditis
Postural tachycardia syndrome (PoTS)
Coagulopathy “Clotting”
Acute myocardial infraction
Anaphylaxis
COVID-19 Disease
Guillain-Barré syndrome
Kawasaki disease
Multisystem Inflammatory Syndrome in children
Multisystem Inflammatory Syndrome in adults
Nacrolepsy / Cataplexy
Pregnancy and Prespecified Conditions
Seisures / Convulsions
Stroke
Transverse Myelitis
If you are filling this out for someone else, did this result in death?
Yes
No
Can you please upload all the emails, letters or PDFs for us to review here
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, eml, Max. file size: 128 MB.
Enter your contact information
Name
First
Last
Email
Phone
Address
Address
City
State / Province / Region
Zip
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Referred By?
Referred By?
Steve Kirsch
react19.org
Lori Bontell
Tom Renz, Esq.
Jeff Childers, Esq.
Mary Holland, Esq.
Robert Barnes, Esq.
Tricia Lindsay, Esq.
Bobbie Anne Flower-Cox, Esq.
Brook Jackson
Sujata Gibson, Esq.
Mark Meuser, Esq.
Tracy Henderson, Esq.
Pierre Kory, MD, MPA
Ryan Cole, MD
Robert Malone, MD
Paul Marik, MD
Meryl Nass, MD
Ralph Lorigo, Esq.
Beth Parlato, Esq.
Dana Wefer, Esq.
Deana Pollard-Sacks, Esq.
Priscilla Romans, RN
Steven M. Warschawsky, Esq.
Nicole Ward
Deborah Conrad, PA-C
Ryan Heath, Esq.
Rachel Rodriguez, Esq.
Kevin Barry, Esq.
Kathryn Huwig
Kyle Moore, Esq.
Scott Lloyd, Esq.
Marcus Thornton
Jeremy Friedman, Esq.
John Pfleiderer, Esq.
Lucia Sinatra
Tom Connors, Esq.
Tyce Patt
Chris Rake, MD
Kelly Mordecai, Esq.
James Mermigis, Esq.
John Beaudoin, Sr.
Lt. Col. (Ret.) Pete Chambers, DO
Rolf Hazlehurst, Esq.
David Gortler
Twitter
On High Alert
Other
Referred By? : Other
Were you given informed consent, verbally, or in writing?
Yes
No
If yes, do you have a printed copy of what you were presented that day?
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, doc, docs, docx, Max. file size: 128 MB.
