Booking Form – Bioweapon Recovery

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First Name*

Last Name*

Email*

Phone*

Gender*

Age*

Body Weight*

Profession or former profession*

What brand of vaccine was administered to you (Pfizer, Moderna, Astra Zeneca, etc)*

One shot, two, or two plus followup boosters?*

Approximately how long ago was the last one?*

What symptoms have you been experiencing since you received your shots or boosters?*

Any co-morbidities (pre-existing health conditions that could have been worsened as a result of the vax) or any other details you would like to share with us

I acknowledge that the patient is able to walk and eat.

How did you hear about us?*