HAVE YOU OR A FAMILY MEMBER BEEN INJURED AS A RESULT OF A REACTION TO THE COVID VACCINATION?

PLEASE HELP ME PUT A STOP TO THE VACCINE MANDATE BY SHARING YOUR EXPERIENCES WITH ME.

Australians Are Suffering Debilitating Reactions To The COVID Vaccine, Some Have Unfortunately Died.

These cases should not be ignored and that’s why I’m calling on you to share your adverse vaccine reaction experience with me.

For months now, I have received letters and messages from Australians and their families who have suffered from adverse reactions to the Covid-19 Vaccines, currently being mandated by many employers and government departments across the nation. Some of the reactions are serious with victims suffering for months whilst others have sadly died in what appears to be from an adverse reaction to their vaccine.

I have also been overwhelmed with the amount of whistleblowers from the medical industry that are coming forward and letting me know about their experiences – from vaccine injuries being covered up, victims not being afforded ample hospital care and the Australian Health Practitioners Association (AHPRA) threatening medical staff, doctors and nurses with de-registration for daring to question the safety of the Covid-19 Vaccines.

PLEASE HELP ME STOP THE COVERUP AND ADDRESS THESE ISSUES SO THAT FAITH CAN BE RESTORED IN OUR MEDICAL SYSTEM.

IF YOU OR A FAMILY MEMBER HAVE SUFFERED AN ADVERSE REACTION AS A RESULT OF THE COVID VACCINE, PLEASE SEND YOUR STORY TO ME.

Please contact me using the form below. Your details will be treated with sensitivity and confidentiality.

If you work in the medical industry and have witnessed adverse reactions, please use the Medical Whistleblower Form.

If you have suffered from a stillbirth or miscarriage please use the Stillbirths & Miscarriages Report Form.

If you work in the medical industry and have witnessed Adverse Events, please use this form to make a submission. Medical Whistleblower Form.

COVID Vax Injuries (18yrs+)

Are you reporting your own reaction or someone else's?

I have had a reaction

An immediate family member has had a severe reaction (incapacitated to submit form) or died

First Name (person filling out this form)

Last Name (person filling out this form)

Phone

Residential Suburb

State

Postcode

First name of injured/deceased?

Last name of injured/deceased?

Occupation of person with the adverse reaction

Sex of person with the adverse reaction

Male

Female

Approximate age or age range of person with adverse reaction

Is this the exact true age of the person?

Yes

Residential state of person with the adverse reaction

How do you know this person (if reporting on another person)?

FIRST VACCINATION INFORMATION

Which COVID Vaccine was administered for the FIRST vaccine? (click to choose)

Date of FIRST vaccine

FIRST Vaccine Batch Number (if known)

Adverse COVID vaccine reactions you/they experienced after FIRST Vaccine (you may select multiple)

Blood Clots/Elevated D-Dimer Test Results

Myocarditis/Pericarditis/Chest Pain

Heart attack/Cardiovascular Damage

Stroke/Simulated Stroke

Paralysis/Numbness in limbs, face and other body parts

Severe headaches/Migraines

Neurological issues/Convulsions

Cognitive/sight disorders

Skin disorders/Hives/Severe Rash

Bleeding

Organ dysfunction

Blood disorders/diabetes/Bruising in area other than injection site

Anaphylaxis

Death

Other Pain

Other (please describe below)

I/They did not experience an above adverse reaction after the first vaccine

Other reaction FIRST vaccine

What medical care was provided after the FIRST reaction?

I/They required a visit to their doctor (has been reported to a doctor)

I/They required a visit to hospital (has been reported to a hospital)

I/They required to stay overnight in hospital (has been reported to a hospital)

I/They required surgery (has been reported to a hospital)

I/They have not reported the reaction to their doctor and have taken over the counter medication to help

No medical care was undertaken and the reaction was not recorded by a GP/hospital

Did the GP/Hospital acknowledge or confirm it was a reaction to the FIRST vaccine?

Yes, they confirmed that it was a vaccine reaction (either verbally or in writing)

They said that it was NOT a vaccine reaction without me/them asking first if it was

I/They said it could be a vaccine reaction and the GP/hospital WOULD NOT acknowledge it or investigate it further

No, there was no mention of it being a Covid Vaccine reaction

They did not seek care so the reaction has not been acknowledged

Were you (parent/guardian) warned about possible adverse reactions by the person administering the FIRST vaccine or their colleague?

Yes, all of them

Some of the reactions

No, I was not told about any of the above reactions

Where did your child have the FIRST vaccine?

GP/Doctor

Pharmacy

Pop-Up Vaccine Clinic/Centre

Other Health Service

Hospital

Place of Employment

Other

Please state where the vaccine was administered if other (first vaccine)

SECOND VACCINATION INFORMATION

Which COVID Vaccine was administered for the SECOND vaccine? (click to choose)

Date of SECOND vaccine

SECOND Vaccine Batch Number (if known)

Adverse COVID vaccine reactions you/they experienced after SECOND Vaccine (you may select multiple)

Blood Clots/Elevated D-Dimer Test Results

Myocarditis/Pericarditis/Chest Pain

Heart attack/Cardiovascular Damage

Stroke/Simulated Stroke

Paralysis/Numbness in limbs, face and other body parts

Severe headaches/Migraines

Neurological issues/Convulsions

Cognitive/sight disorders

Skin disorders/Hives/Severe Rash

Bleeding

Organ dysfunction

Blood disorders/diabetes/Bruising in area other than injection site

Anaphylaxis

Death

Other Pain

Other (please describe below)

I/They did not experience an above adverse reaction after the second vaccine

Other reaction SECOND vaccine

What medical care was provided after the SECOND reaction?

I/They required a visit to their doctor (has been reported to a doctor)

I/They required a visit to hospital (has been reported to a hospital)

I/They required to stay overnight in hospital (has been reported to a hospital)

I/They required surgery (has been reported to a hospital)

I/They have not reported the reaction to their doctor and have taken over the counter medication to help

No medical care was undertaken and the reaction was not recorded by a GP/hospital

Did the GP/Hospital acknowledge or confirm it was a reaction to the SECOND vaccine?

Yes, they confirmed that it was a vaccine reaction (either verbally or in writing)

They said that it was NOT a vaccine reaction without me/them asking first if it was

I/They said it could be a vaccine reaction and the GP/hospital WOULD NOT acknowledge it or investigate it further

No, there was no mention of it being a Covid Vaccine reaction

They did not seek care so the reaction has not been acknowledged

Were you warned about possible adverse reactions by the person administering the SECOND vaccine or their colleague?

Yes, all of them

Some of the reactions

No, I was not told about any of the above reactions

Where did your child have the SECOND vaccine?

GP/Doctor

Pharmacy

Pop-Up Vaccine Clinic/Centre

Other Health Service

Hospital

Place of Employment

Other

Please state where the vaccine was administered if other (second vaccine)

THIRD VACCINATION INFORMATION

Which COVID Vaccine was administered for the THIRD vaccine? (click to choose)

Date of THIRD vaccine

THIRD Vaccine Batch Number (if known)

Adverse COVID vaccine reactions you/they experienced after THIRD Vaccine (you may select multiple)

Blood Clots/Elevated D-Dimer Test Results

Myocarditis/Pericarditis/Chest Pain

Heart attack/Cardiovascular Damage

Stroke/Simulated Stroke

Paralysis/Numbness in limbs, face and other body parts

Severe headaches/Migraines

Neurological issues/Convulsions

Cognitive/sight disorders

Skin disorders/Hives/Severe Rash

Bleeding

Organ dysfunction

Blood disorders/diabetes/Bruising in area other than injection site

Anaphylaxis

Death

Other Pain

Other (please describe below)

I/They did not experience an above adverse reaction after the third vaccine

Other reaction THIRD vaccine

What medical care was provided after the THIRD reaction?

I/They required a visit to their doctor (has been reported to a doctor)

I/They required a visit to hospital (has been reported to a hospital)

I/They required to stay overnight in hospital (has been reported to a hospital)

I/They required surgery (has been reported to a hospital)

I/They have not reported the reaction to their doctor and have taken over the counter medication to help

No medical care was undertaken and the reaction was not recorded by a GP/hospital

Did the GP/Hospital acknowledge or confirm it was a reaction to the THIRD vaccine?

Yes, they confirmed that it was a vaccine reaction (either verbally or in writing)

They said that it was NOT a vaccine reaction without me/them asking first if it was

I/They said it could be a vaccine reaction and the GP/hospital WOULD NOT acknowledge it or investigate it further

No, there was no mention of it being a Covid Vaccine reaction

They did not seek care so the reaction has not been acknowledged

Were you warned about possible adverse reactions by the person administering the THIRD vaccine or their colleague?

Yes, all of them

Some of the reactions

No, I was not told about any of the above reactions

Where did you have the THIRD vaccine?

GP/Doctor

Pharmacy

Pop-Up Vaccine Clinic/Centre

Other Health Service

Hospital

Place of Employment

Other

Please state where the vaccine was administered if other (third vaccine)

OTHER INFORMATION

Are you satisfied with how the doctor or medical team are handling/handled your/the patient's care?

Not Sure/No Outcome

Definitely

Yes

Somewhat

Definitely Not

Has your/the person's adverse reaction/s been recorded with the TGA (Therapeutic Goods Administration)?

I'm not sure

A doctor/medical provider has recorded it with the TGA

I/They have recorded it with the TGA

No, nobody has reported it officially with the TGA

I/They did not want the adverse reaction recorded with the TGA

I'm not sure, I'm reporting on someone else

If known, which reactions were recorded with the TGA?

Blood Clots/Elevated D-Dimer Test Results

Myocarditis/Pericarditis/Chest Pain

Heart attack/Cardiovascular Damage

Stroke/Simulated Stroke

Paralysis/Numbness in limbs, face and other body parts

Severe headaches/Migraines

Neurological issues/Convulsions

Cognitive/sight disorders

Skin disorders/Hives/Severe Rash

Bleeding

Organ dysfunction

Blood disorders/diabetes/Bruising in area other than injection site

Anaphylaxis

Death

Other Pain

Other (please describe below)

If other, which reactions?

Have you received the autopsy report back from the Coroner?

Yes

An autopsy was not performed/Not applicable

Did the autopsy mention the miscarriage/stillbirth as potentially being caused by a Covid Vaccine

Yes

What was the ultimate cause/causes of death listed in the autopsy?

Upon receiving the autopsy report, did the State Coroner place a 'Non-Publication or Disclosure' condition on the report?

Yes

I'm not sure

What is the name of the Coroner?

What is the name of the Forensic Pathologist who performed the autopsy?

Did you/they have to take any days off work due to adverse reactions?

Yes, I/they took sick leave

Yes, I/they took annual leave

Yes, I/they am self-employed

Yes, I/they took a mix of sick and annual leave

No, I/they was/were okay to continue to work

I'm not sure as I'm reporting on someone else

How many days off work did you/they have in total so far?

Did you/they volunteer to get the vaccine or was it imposed by an employer?

I/They volunteered on our/their own to get the vaccine and were happy to get it

I/They volunteered on our/their own to get the vaccine but had some concerns about its safety

I/They felt pressured by their employer to get the vaccine and didn't really want to get it

I/They were told that they would lose their job if they did not get the vaccine and felt like they had no choice but to get it

I/They didn't want to get it but felt pressured by family/friends/community members/media/politicians

I/They didn't want to get it but were fearful of being refused entry to shopping centres, businesses, entertainment venues, sporting events and restaurants etc

Other reason (please describe below)

Other reason

Have you/they had a COVID-19 Infection?

Yes, before any vaccines

Yes, after the first vaccine

Yes, after the second vaccine

Yes, after the third vaccine

Maybe but I/they did not take a PCR or RAT test to confirm

No, they have never had Covid

I'm not sure

Have you/they got a temporary exemption from having any more Covid Vaccines?

Yes

No, I/they are not eligible

No and I'm not sure if eligible

No, my/their doctor will not give one

I'm not sure, I'm reporting on someone else

Please provide any other information here (more information section)

You may upload supporting evidence/documentation/images here

Choose File

Would you like me to share this on social media to raise awareness?

Yes

I'm not sure (maybe in the future)

If you select YES you consent to Senator Gerard Rennick publishing your story on his social media channels.

Would you like me to share this report with other government departments or in Senate inquiries?

Yes

Yes, but please redact my name

I'm not sure (maybe in the future)

If you select YES you consent to Senator Gerard Rennick publishing this report with government departments or Parliamentary Inquiries. This report will only be published if consent is given by the person injured or their next of kin (if deceased).

I consent to Senator Gerard Rennick contacting me in the future. I understand I can opt-out of email communications at any time.

YES

HAVE YOU OR A FAMILY MEMBER BEEN INJURED AS A RESULT OF A REACTION TO THE COVID VACCINATION?

PLEASE HELP ME PUT A STOP TO THE VACCINE MANDATE BY SHARING YOUR EXPERIENCES WITH ME.

Australians Are Suffering Debilitating Reactions To The COVID Vaccine, Some Have Unfortunately Died.

These cases should not be ignored and that’s why I’m calling on you to share your adverse vaccine reaction experience with me.

PLEASE HELP ME STOP THE COVERUP AND ADDRESS THESE ISSUES SO THAT FAITH CAN BE RESTORED IN OUR MEDICAL SYSTEM.

IF YOU OR A FAMILY MEMBER HAVE SUFFERED AN ADVERSE REACTION AS A RESULT OF THE COVID VACCINE, PLEASE SEND YOUR STORY TO ME.

Please contact me using the form below. Your details will be treated with sensitivity and confidentiality.

FIRST VACCINATION INFORMATION

SECOND VACCINATION INFORMATION

THIRD VACCINATION INFORMATION

OTHER INFORMATION

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