Chemical Illness Report Form

Use the form below to report health problems suspected from chemical or pesticide exposure.  We are also asking people to report improper use or disposal of chemicals.  After filling out the form below - your "story" will be posted on our "Chemical Illness Report Page" at Chem-Tox.com.   This can then be seen by the thousands of people visiting our site weekly.  It is extremely important that others be made aware of the wide-range of health problems resulting from petroleum based chemicals used in today's society.   Please use lowercase for writing and keep descriptions limited to no more than several paragraphs which makes it easier for our visitors to browse through the abstracts.  Also, we recommend you include your email address so that you can be contacted by other people who may have suggestions or be able to help. After submitting your information below, it will be added to our Health Problems site typically within several hours. Thank you - Chem-Tox

Choose a Title to draw attention to your circumstance:
 Title:

Describe the Problem in Detail Limit to 1 or 2 paragraphs

City: State: Country:

Email Address:

Thank you - click SUBMIT below to post your information

* Back to Chemical Illness Report Page - You may have to hit "refresh" to view what you have just posted.  If you find you have mad a significant error in your posting - contact research@chem-tox.com and we will correct it.